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Family Caregiver Guide

M E D I C A R E

Florida’s Blue Cross and Blue Shield Plan

Name

This guide contains resources to help you:

Organize contact information

Record medical concerns

Track medications

Conduct safety inspections

Log daily care routines

We recommend you assign a single caregiver to update information and share with others so you always know the information is up to date.

3 What is a Caregiver?

A caregiver is a person who provides needed help to an aging or ill

loved one. Caregivers may supply emotional support, physical assistance,

financial assistance and many other types of care.

Being a family caregiver can be rewarding, but it can also be challenging. It takes work and there are a lot of things to keep up with. We’ve created the Florida Blue

Family Caregiver Guide to help

you keep track of your loved

one’s information.

How to use this guide

If you complete the guide online, you can download and save it as a PDF for access from anywhere. Save a copy on your smartphone, tablet or in a file-sharing cloud service for real-time access any time.

Don’t want to complete the information online? Just print and fill out the forms by hand instead.

Download Acrobat for Mobile https://acrobat.adobe.com/us/en/mobile/acrobat-reader.html

Sharing the family caregiver role? Share the guide with others by sending it to them as a file or giving them a printed copy.

To avoid confusion, we recommend you assign a single caregiver to update information and share with others so you always know the information is up to date.

Caring for more than one loved one?

Complete a guide for each person and keep track of their personal information separately.

This easy-to-use guide gives you a place to record important information and keep it close at hand.

Inside, you’ll find forms you can complete online and easily update as things change.

We recommend that you keep this document in a secure place, because it contains personal information. Just make sure it’s readily accessible when you need it.

Tips for Saving and Accessing Your Completed Guide:

Table of Contents

If there is a serious health situation, I need to remember these things:

1. 2. 3.

SECTION 1 Important Phone Numbers

SECTION 2 Health Insurance Information

SECTION 3 Medical Information

SECTION 4 Medications

SECTION 5 Provider Information

SECTION 6 Routines and Activities

SECTION 7 Wellness Tracking

SECTION 8 Safety

SECTION 9 Elder Care Services

SECTION 10 Managing Your Loved One’s Diet SECTION 11 Notes

5-9

10-11

12-17

18-24

25-27

28-29

30-31

32-34

35-37

38-40

41-51

Important Phone Numbers Be Prepared! Have key health care providers, support resources and emergency numbers available.

SECTION 1

Important Phone Numbers

Name

Relationship

Address

City State Zipcode

Phone Number Email

Name

Relationship

Address

City State Zipcode

Phone Number Email

Name

Relationship

Address

City State Zipcode

Phone Number Email

Name

Relationship

Address

City State Zipcode

Phone Number Email

Family

Name

Address

City State Zipcode

Phone Number Email

Name

Address

City State Zipcode

Phone Number Email

Address

City State Zipcode

Phone Number Email

Address

City State Zipcode

Phone Number Email

Name

Address

City State Zipcode

Phone Number Email

Name

Address

City State Zipcode

Phone Number Email

Important Phone Numbers (continued)

Friends

Neighbors

Preferred Hospital

Name Condition

Phone

Address

Name Condition

Phone

Address

Name Condition

Phone

Address

Name Condition

Phone

Address

Name Condition

Phone

Address

Name Condition

Phone

Address

Important Phone Numbers (continued)

City State Zipcode

City State Zipcode City State Zipcode

Doctors

Non-911 Emergency Services

Preferred Pharmacy

Name

Phone

Notes

Name Condition

Phone

Address

Name Condition

Phone

Address

Important Phone Numbers (continued)

Name

Phone

Notes

City State Zipcode City State Zipcode

Health Insurance Information Record your loved one’s health insurance plan and coverage information in one place for easy access.

SECTION 2

Health Insurance Information Medicare

Website https://www.cms.gov/Medicare/Medicare.html

Member Number

Health Insurance

Name Phone Website

Member Name Plan Name ❍ Medicare Advantage ❍ Medicare Advantage Rx ❍ Medicare Supplement

Other Health Insurance

Contact Information

Name Phone Website

Member Name Plan Name Plan Name

Dental Insurance

Contact Information

Name Phone Website

Member Name Plan Name Plan Name

Vision Insurance

Contact Information

Name Phone Website

Member Name Plan Name Plan Name

Medical Information Keep track of your loved one’s medical information:

Health conditions

Procedures and hospitalizations

Medicines and allergies

SECTION 3

Medical Information

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Medical Conditions and Health Issues

Medical Information (continued)

Did you include dental, vision and hearing concerns? Mental health conditions are also important to track, so don’t leave them off the list.

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Condition/Issue Date Started

_______/ _______/ _______

Symptoms Treatments

Notes

Medical Conditions and Health Issues

Medical Information (continued)

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Medical Procedure History List all procedures — including dental and any surgeries.

Hospitalization History

Medical Information (continued)

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Procedure Reason Date Started

_______/ _______/ _______

Hospital/Facility Doctor

Hospitalization History

Medical Information (continued) Does your loved one use medical equipment for safety or mobility? Keep track of them here.

Bathroom

 Elevated toilet seat

 Toilet safety frame

 Shower bench

 Tub transfer bench

 Grab bars

 Other

Mobility

 Cane

 Walker

 Wheelchair

 Scooters/electric wheelchair

 Other

Bedroom

 Hospital bed

 Bedside commode

 Bedpan/urinal

 Other

Transferring

 Lift chair

 Floor to ceiling transfer pole

 Hoyer lift

 Other

General Safety  Personal emergency

response systems (These are systems that provide a button transmitter, usually worn as a neck pendant or wristband, which when pushed connects the user to a 24 hour per day call center.)

 Other

Medications Keep track of your loved one’s medications.

Prescription Drugs

Over-the-Counter Medications

Vitamins and Supplements

SECTION 4

Medications

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Prescription Drugs

Medications (continued)

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Prescription Drugs (continued)

Medications (continued)

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Drug Name Related Condition Prescribing Doctor

Dose & Frequency Pharmacy Name Pharmacy Phone

Last Refill Date _______/ _______/ _______

Next Refill Date _______/ _______/ _______

Reactions Effectiveness

Notes

Prescription Drugs (continued)

Medications (continued) Over-the-Counter Medicine Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Medicine Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Medicine Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Medicine Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Medicine Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Medications (continued) Vitamins and Supplements

Vitamin Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Vitamin Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Vitamin Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Vitamin Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Vitamin Name Related Condition

Dose & Frequency Reactions Effectiveness

Notes

Medications (continued)

See if your loved one is eligible for PillPack.

Medication Dose Precautions Morning Midday Evening Bedtime

Medication Reaction

Tip: Get a pill organizer you can load once a week to minimize confusion.

Daily Medication Schedule

Medication Allergies

Provider Information Keep track of your loved one’s medical care community:

Doctors

Hospitals

Urgent Care

SECTION 5

Provider Information

Doctor Name Specialty Facility Phone Number Date of Last Visit

____/ ____/ _____

Provider Contact Information

Provider Information (continued)

Name Phone Number Address

Closest Florida Blue Center To find your closest center visit floridablue.com/find-a-floridablue-center

Address

Phone Number

Clinics

Hospitals

Routines and Activities Keep track of your loved one’s social activities and wellness routines.

SECTION 6

Routines and Activities Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Activity Location

Wellness Tracking Be aware of over-65 preventive screening and immunization recommendations and track your loved one’s information.

Always consult your loved one’s doctor for the best course of action.

SECTION 7

Wellness TrackingPreventive Care Guidelines for ages 65+ Schedule an Annual Wellness Visit or your Welcome to Medicare Preventive Visit with your doctor to discuss preventive screenings and the flu vaccine. Before you go, make sure that your Medicare plan benefits cover these services.

Routine Health Guide Annual Wellness and Routine Checkup Annually

Welcome to Medicare Preventive Visit Once per lifetime, within 12 months of first having Medicare Part B coverage

Obesity Screening: Diet/Physical Activity/BMI Counseling Annually

Vision Exam, Glaucoma Screening and Dental Exam Annually

Abdominal Aortic Aneurysm (AAA) Check One-time screening in a lifetime: Discuss with your doctor*

Lung Cancer Screening and Counseling

Annually for ages 55–80; with a 30-pack per year smoker history, current smoker or those who have quit smoking within the past 15 years

High Blood Pressure (hypertension) Annually

Diabetic Screening, Blood Sugar, Hemoglobin A1C, Retinal Eye Exam, Kidney Function, Blood Pressure Annually

Osteoporosis Every 24 months or more often if medically necessary, discuss with your doctor

Colorectal Cancer Screening and Counseling**

Ages 50–75; Screening Colonoscopy every 10 years, FOBT (Fecal occult blood test) every year or FIT-DNA every 2 years, CT colonography every 5 years or Sigmoidoscopy every 5 years

HIV and other Sexually Transmitted Infections (STIs) Screening & Counseling Annually; discuss with your doctor

Cholesterol Screening Once every 5 years; more frequently if at risk; discuss with your doctor.

Prostate Cancer Screening (Men only) Discuss with your doctor

Mammogram (Women only) Once every 5 years; more frequently if at risk; discuss with your doctor

Pap Test/Pelvic Exam (Women only) Once every 5 years; more frequently if at risk; discuss with your doctor

Skin Cancer Screening. Early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.

Discuss with your doctor

Hearing Test Discuss with your doctor

Recommended Diagnostic Checkups & Screenings for At-Risk Patients

Preventive Screenings and Guidance for Seniors

Safety Take basic steps to ensure your loved one’s safety with:

Fall Prevention Checks

Medicine Safety

Home Safety Assessments

SECTION 8

Safety

Floors

 Is furniture blocking or impeding path?

 Are throw rugs fastened with double-sided tape or do they have non-slip backing?

 Is there clutter on the floor that may cause trips and falls?

 Are wires or cords crossing walkways?

Stairs & Steps

 Do stairways have bright lighting and working lightbulbs?

 Is carpet on steps firmly attached?

 Are handrails available on both sides of stairs?

 Are handrails securely fastened?

 Is there clutter on stairs?

 Are light switches available at both top and bottom of staircase?

Kitchen  Are regularly used items on low,

easy-to-access shelves (waist level)?

 If a step stool is available, is it steady and are there handles to hold onto?

Bathroom

 Is there a non-slip mat or strips on the tub or shower floor?

 Are grab bars available in the tub, shower or next to the toilet?

Bedroom

 Is there a light near the bed in an easy-to-reach location?

 Is there a lighted path from the bed to the bathroom?

Fall Prevention Checklist

Safety (continued)

Home Safety Checklist

 Ensure furniture is not resting on electric cords, leading to damage and fire/shock hazards.

 Ensure cords out from underneath furniture and rugs.

 Ensure cords are not attached to walls by nails or staples.

 Inspect electrical cords to ensure they are in good condition and not frayed or cracked.

 Ensure extension cords are not overloaded.

 Test smoke detectors to ensure they are working properly, and change batteries regularly.

 Ensure all outlets and switches have cover plates and wiring is not exposed.

 Ensure portable heaters are out of walkways, in locations where they can’t be knocked over and away from flammable materials such as curtains or rugs.

 Ensure your loved one knows all the exit routes, and that they are free of clutter, in case of fire or emergency. Practice them regularly.

 Ensure towels, curtains and other flammable items are located away from the cooking range.

 Ensure cooking areas are well-lit to prevent burns or cuts.

 Check window and door locks to ensure they are functioning and easy to open.

Elder Care Services Whether work and family make demands, or you simply need to spend some time alone, you can’t always be there. Track resources available to help support your loved one.

Elder Care Services

Family & Community Support

Transportation & Meals

Social Activities

SECTION 9

Elder Care Services

Name Contact Information Services Available

Name Contact Information Availability

Name Contact Information Schedule

Service Providers

Family

Meal Programs

Elder Care Services (continued)

Department of Health and Human Services Elder Care Locator

Activity Name Contact Information Schedule

Name Contact Information

Social Activities

Transportation

eldercare.gov Use the Elder Care Locator to find the local area agency on aging for any area of the country, by zip code. The local area agency on aging can help you locate local medical equipment providers and personal emergency response system providers.

1-800-677-1116

Managing Your Loved One’s Diet Keep track of diet and nutrition plans:

Dietary goals

Food allergies and preferences

SECTION 10

Managing your loved one’s diet

Foods to Increase:

Foods to Avoid:

When Possible, Offer Choices. Giving your loved one choices maintains their sense of independence. Whenever possible, give your loved one a chance to choose what to eat.

Managing your loved one’s diet (continued) Food Preferences:

Food Dislikes:

Food Sensitivities/Allergies:

Sensitivities/Allergies Reactions

Notes SECTION 11

Whether recording caregiver activities and concerns or doctor’s appointment outcomes, use this space to collect your thoughts and use as a reference.

Notes Date Notes Special Concerns

_____/ _____/ _______

Caregiver’s Notes:

Notes Date Notes Special Concerns

_____/ _____/ _______

Caregiver’s Notes:

Notes Date Notes Special Concerns

_____/ _____/ _______

Caregiver’s Notes:

Notes Doctor’s Appointment Notes

Appointment Overview:

Date _____/ _____/ _______

Doctor