GuidingCare - Member Profile

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Jackson Thomas DOB 03/15/1958 · MBR-2024-3742

Maria Rivera DOB 08/22/1975 · MBR-2024-8516

Robert Chen DOB 11/03/1982 · MBR-2024-2947

Sarah Williams DOB 06/17/1990 · MBR-2024-6183

James O'Connor DOB 02/28/1968 · MBR-2024-9025

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Assigned Type Enrollment Status Risks

	Eligibility	Last Name arrow_upward	First Name	New ID	DOB	Risk	Next Contact	Assigned Date	Program Name
check_circle	Active	Thomas	Jackson	MBR-2024-3742	03/15/1958	High	04/01/2026	01/15/2024	Diabetes Management
check_circle	Active	Rivera	Maria	MBR-2024-8516	08/22/1975	--	--	03/01/2025	Health Risk Assessment
check_circle	Active	Chen	Robert	MBR-2024-2947	11/03/1982	Low	04/10/2026	02/10/2025	Fall Prevention
check_circle	Active	Williams	Sarah	MBR-2024-6183	06/17/1990	Medium	04/12/2026	02/20/2025	Maternal Health
check_circle	Active	O'Connor	James	MBR-2024-9025	02/28/1968	High	04/08/2026	01/05/2025	Behavioral Health

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Alerts

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Alert Source Alert Description

Description	Member(s)	Source	Updated On
ER visit reported	1	Claims	03/23/2026

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Module Type Member Name Risk Type Risk Level From Date calendar_month To Date calendar_month Work Queue

	Member Name	Refer Date	Refer by	Refer To	Status	WQ
	Adam Eve	07/25/2025	Jennifer Reyes	Beatrice Kanya	Pending

Member Details

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Personal Details

Member Name (F-M-L): AM2 Test

Preferred Name: Not Available

Gender: Male

Gender Identity: Not Available

Sexual Orientation: Not Available

Preferred Pronouns: Not Available

Date of Birth: January 01, 2001

New ID: ALT9713

Member ID: Not Available

Preferred Contact Format: Not Available

Service Interruption: Not Available

Phone Numbers

Preferred Phone: Not Available

Primary Phone: Not Available

Cell Phone: Not Available

Alternate Phone: Not Available

Fax: Not Available

Preferred Time to Call: Not Available

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Primary Email: Not Available

Preferred Email: Not Available

Alternate Email: Not Available

Clinical Details

Primary Medical Provider: Not Available

Primary Medical Condition: Not Available

Primary Behavioral Condition: Not Available

Expected Risk: Not Available

Sensitive Diagnosis: No

Doctor appt.: Not Available

Reason for Doctor appt.: Not Available

EPSDT Member: No

Member Portal

Member Portal Access: Not Available

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Languages

Primary Language: Not Available

Preferred Written Language(s): Not Availa...

Preferred Spoken Language(s): Not Available

Communication Impairment: Not Available

Address

Address: 123 Main Street

City: Not Available

State / Province: Not Available

Zip / Postal Code: Not Available

County: Not Available

Country: Not Available

Medical IDs

Primary Insurance: Not Available

Primary Ins. Policy #: Not Available

Secondary Insurance: Not Available

Secondary Ins. Policy #: Not Available

Demographics

Race: Not Available

Preferred Race: Not Available

Ethnicity: Not Available

Preferred Ethnicity: Not Available

Residence Status: Not Available

Income Status: Not Available

Marital Status: Not Available

Veteran Status: Not Available

Evacuation Zone: Not Available

Aid Supplemental Data

Aid Supplemental Data: View Aid/Supplemental Data History

arrow_right Phone Numbers

No additional phone numbers on file.

arrow_right Addresses

Address: 123 Main Street

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No privacy group contacts on file.

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No family details on file.

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No additional identifiers on file.

arrow_right Additional Information

No additional information on file.

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No risk additional information on file.

	First Name	Last Name	Home Phone	DOB	Gender	Relation	Caregiver Type	Is Primary	Start Date	End Date
	Maria	Thomas	(907) 555-0142	06/22/1960	Female	Wife	Primary Caregiver	check_circle	01/15/2020

Name	Role	Phone	Email	Start Date
Dr. Sarah Chen	Primary Care Physician	(907) 555-0300	s.chen@alaskapremier.org	01/01/2024
Jennifer Reyes, RN	Care Manager	(907) 555-0312	j.reyes@alaskapremier.org	02/15/2024
Dr. Michael Park	Cardiologist	(907) 555-0418	m.park@anchoragecardio.com	03/01/2024

Program Name	Status	Start Date	End Date
Diabetes Management	Active	01/15/2024
Cardiac Rehab	Active	03/01/2024
Fall Prevention	Completed	06/10/2023	12/15/2023

Current Eligibility Active

Health Plan: Alaska Premier Health

LOB: Medicare Advantage

Effective Date: 01/01/2024

Term Date: 12/31/2024

Status: Active

Member ID: MBR-2024-3742

Group: GRP-AK-001

Eligibility History

Plan	LOB	Effective Date	Term Date	Status
Alaska Premier Health	Medicare Advantage	01/01/2024	12/31/2024	Active
Alaska Premier Health	Medicare Advantage	01/01/2023	12/31/2023	Termed
Northern Health Alliance	Medicare Supplement	03/15/2021	12/31/2022	Termed

Test Date	Test Type	Result	Ordered By
03/10/2024	HbA1c	7.2%	Dr. Sarah Chen
02/28/2024	Lipid Panel	Normal	Dr. Michael Park
01/15/2024	BMP (Basic Metabolic Panel)	Normal	Dr. Sarah Chen
12/20/2023	HbA1c	8.1%	Dr. Sarah Chen

Member Medical Info

Visits

Diagnosis

Medications

Health Indicators

Appointments

Primary Medical Conditions:	Not Available	Primary Behavioral Conditions:	Not Available
Additional Medical Health Info:	Not Available	Additional Behavioral Health Info:	Not Available
Secondary Medical Conditions:	Not Available	Secondary Behavioral Conditions:	Not Available
Height:	Not Available	Weight:	Not Available
Communication Impairment:	Not Available	Care Manager:	Beatrice Kanya
Programs:	CHNCT Diabetes Program	Service Interruption:	Not Available
Evacuation Zone:	Not Available

play_arrow Risk Stratification Information

No risk stratification data available.

play_arrow Allergies & Sensitivities

No allergies or sensitivities recorded.

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No vaccination records available.

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No preventive screening records available.

Primary Medical Condition : Not Available

Enrollment Months : FEP : 2 years, 3 months, 24 days (845 days)

Opportunity	Identified Date	Status	Created By	Created On	Updated By	Updated On	Source Type
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Opportunity	Identified Date	Status	Created By	Created On	Updated By	Updated On
Member does not have a provider that can help them manage their diabetes	02/09/2026	Added	Sridevi Palepu	02/09/2026	N/A	N/A
Consider referring member to a transportation Vendor to get help for transportation	02/08/2024	Added	Sridevi Palepu	02/08/2024	N/A	N/A
Comprehensive Diabetes Care	09/29/2021	Added	Dina Maiorana	09/29/2021	Dina Maiorana	09/29/2021

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	Preference	Task	Member Goal	Member Status	Start Date	Target Date	Care Staff Comments	Member Comments
⚑	High	I will meet PCP and get hba1c tested	N/A	InProgress	09/29/2021	10/04/2021	N/A	N/A
⚑	High	Educate member about lifestyle modification	N/A	New	09/29/2021	06/28/2022	N/A	N/A
⚑	High	Document members desired action regarding a provider to manage their diabetes	Document members desired goal regarding a provider to manage their diabetes	New	02/09/2026	03/10/2026	N/A	N/A

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		Auth ID	Description	Service From Date	Service To Date	App. Units	Freq.	Status	Approved Date	PCS Form	Benefit Limit	Provider Ack.	Member Ack.
chevron_right		0515T5TM1	info Established patient office or … More..	05/14/2025	05/15/2025	1	N/A	Approved	05/29/2025	N/A	N/A	— —	— —
chevron_right			info Established patient office or … More..	05/14/2025	05/17/2025	3	N/A	Pended	N/A	N/A	N/A	— —	— —

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Advance Directive Type	Addressed Date	Completion Date	Created By	Created On	Updated By	Updated On	File
DNI	05/15/2024	N/A	Sridevi Palepu	05/14/2024	N/A	N/A	N/A
Five Wishes	05/15/2024	05/15/2024	Sridevi Palepu	05/14/2024	Sridevi Palepu	05/14/2024
DNI	N/A	N/A	Sridevi Palepu	05/14/2024	Sridevi Palepu	05/14/2024	N/A

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Note Type	Notes	View Notes	Activity Type	Script Name	Created By	Created On	Updated By	Updated On
Clinical Note	Member reports increased fatigue and polyuria over the past two weeks. Current A1C of 8.4% indicates suboptimal glycemic control. Discussed medication adherence barriers — member states he occasionally forgets evening insulin dose. Reinforced importance of consistent dosing schedule and provided written reminder tips. Will coordinate with PCP Dr. Chen for potential Metformin dosage adjustment. Follow-up call scheduled for 04/08/2026.	visibility	N/A	N/A	Sarah Mitchell, RN : Care Manager	03/20/2026 10:14:22 AM	N/A	N/A
Care Coordination Note	Contacted Providence Medical Center to obtain discharge summary from 03/05/2026 ED visit. Member presented with chest pain, ruled out for ACS, diagnosed with GERD exacerbation. Coordinated with cardiologist Dr. Park to schedule follow-up echocardiogram. PCP notified of ED visit and updated medication list shared via HIE.	visibility	N/A	N/A	James Okafor, CCM : Care Coordinator	03/12/2026 02:37:41 PM	N/A	N/A
Telephonic Outreach Note	Attempted outreach call to member at (907) 555-0142 — no answer, left voicemail. Second attempt at cell (907) 555-0198 successful. Member reports feeling stable, denies SOB or chest pain. States he has been compliant with Lisinopril and Atorvastatin. Reminded member of upcoming PCP appointment on 03/28/2026. Member verbalized understanding.	visibility	N/A	N/A	Diana Reyes, MSW : Care Manager	03/01/2026 09:45:18 AM	N/A	N/A
Social Determinants Note	During SDOH screening, member disclosed difficulty affording prescription co-pays since spouse's retirement. Identified food insecurity — member reports skipping meals 2-3 times/week. Referred to Alaska Food Bank and Community Action Program for utility assistance. Submitted application for pharmaceutical patient assistance program for Januvia. Member expressed gratitude and willingness to engage with community resources.	visibility	N/A	N/A	Diana Reyes, MSW : Social Worker	02/18/2026 11:22:03 AM	N/A	N/A
Medication Management Note	Comprehensive medication reconciliation completed via telehealth. Member currently on 9 medications including Metformin 1000mg BID, Januvia 100mg daily, Lisinopril 20mg daily, Atorvastatin 40mg daily, and ASA 81mg daily. Identified potential interaction between newly prescribed Fluconazole and Atorvastatin — notified prescribing physician. Pharmacist consulted and recommends temporary statin hold. Care plan updated accordingly.	visibility	N/A	N/A	Tom Callahan, RN : Clinical Pharmacist	02/05/2026 03:55:09 PM	Priya Nandakumar, CCM : Care Manager	02/06/2026 08:12:44 AM

Performed On	Performed By	Scheduled Date	Scheduled By	Activity Type	Eligibility	Program Name	Activity Outcome	View	Delete
03/20/2026 10:30 AM	Sarah Mitchell, RN	N/A	N/A	Telephonic Outreach	N/A	N/A	Completed	visibility	Delete
03/12/2026 02:00 PM	James Okafor, CCM	N/A	N/A	Care Coordination	N/A	N/A	Completed	visibility	Delete
03/01/2026 09:45 AM	Diana Reyes, MSW	N/A	N/A	Telephonic Outreach	N/A	N/A	Completed	visibility	Delete
02/18/2026 11:00 AM	Diana Reyes, MSW	N/A	N/A	SDOH Screening	N/A	N/A	Completed	visibility	Delete
02/05/2026 03:30 PM	Tom Callahan, RN	N/A	N/A	Medication Reconciliation	N/A	N/A	Completed	visibility	Delete
N/A	N/A	04/08/2026	Priya Nandakumar, CCM	Follow-Up Call	N/A	N/A	Scheduled	visibility	Delete

Program Name	Activity Type	Script Name	Due Date	Recurring
N/A	Appointment Reminder	N/A	01/31/2020		settings bar_chart
13243	N/A	01/31/2020		settings bar_chart
Assessments - Condition Based	N/A	02/29/2020		settings bar_chart
Assessments - Initial Outreach	N/A	02/29/2020		settings bar_chart

Activity Type	Script Name	Due Date
No Records Found

Document ID	Document	View	Type	Draft	Resend	Member Portal
3650	IDD Non Usage of one Service		Letter Draft	picture_as_pdf description	N/A	Share
3627	IDD Non Usage of one Service.pdf	visibility	Letter Document		info content_copy	Share
3622	EL Welcome Letter.pdf	visibility	Letter Document		info content_copy	Share
3593	TEST_TEMPLATE_CMS.pdf	visibility	Letter Document		info content_copy	Share
3566	test 4.pdf	visibility	Letter Document		info content_copy	Share
3559	Test training.pdf	visibility	Letter Document		info content_copy	Share
3558	Test training.pdf	visibility	Letter Document		info content_copy	Share
3504	Full Care Plan.pdf	visibility	Care Plan		N/A	Share
3503	Full Care Plan.pdf	visibility	Care Plan		N/A	Share
3264	screenshot-2.png	visibility	Care Literature		N/A	Share

Article Title	Description	Source	Article Type	Send On	Status	Resend	Download
Understanding Your A1C: What the Numbers Mean	Learn what your A1C test measures and how to interpret your results to better manage your diabetes.	GuidingCare	Chronic Disease Management	03/15/2026	Read	N/A	download
Heart-Healthy Eating on a Budget	Practical tips for choosing affordable, nutritious foods that support cardiovascular health.	GuidingCare	Nutrition	03/01/2026	Unread	N/A	download
Managing Multiple Medications Safely	How to organize your medications, avoid harmful interactions, and stay on track with your prescriptions.	GuidingCare	Medication Safety	02/18/2026	Read	N/A	download
Community Resources for Seniors in Alaska	A guide to local programs offering food assistance, transportation, and social support for older adults.	GuidingCare	Social Support	02/05/2026	In Progress	N/A	download

ROI Form	ROI To	Status	ROI Active	Valid From Valid To	Care Staff	Remarks
Authorization to Release Health Information	Providence Medical Center	Signed	check_circle	01/15/2026 01/15/2027	Sarah Mitchell, RN	Member signed ROI for discharge records and lab results from Providence ED visit.
Care Management Program Consent	Alaska Premier Health	Signed	check_circle	10/22/2025 10/22/2026	James Okafor, CCM	Consent obtained for participation in Complex Care Management program.
Telehealth Services Consent	N/A	Pending		N/A N/A	Priya Nandakumar, CCM	Awaiting member signature for telehealth consent — form mailed 03/10/2026.

Guideline Name	Episode ID	Created By	Date Created	View Documentation	View Episode Summary
HEDIS Comprehensive Diabetes Care	EP-2026-0412	Sarah Mitchell, RN	01/15/2026	visibility	summarize
ACC/AHA Guideline for Management of Heart Failure	EP-2026-0398	James Okafor, CCM	02/10/2026	visibility	summarize
USPSTF Statin Use for Primary Prevention of CVD	EP-2026-0445	Tom Callahan, RN	03/05/2026	visibility	summarize

Status	Member Alert Description	Source Alert Description	Alert Date
New	Gap in Care — HbA1c test overdue	HEDIS measure CDC: Member has not completed HbA1c testing within the past 6 months. Last recorded A1C was 8.4% on 09/18/2025. Outreach required to schedule lab work.	03/22/2026
Active	Readmission Risk — ED visit within 30 days	Member had ED visit on 03/05/2026 for chest pain (R/O ACS). LACE index score of 11 indicates high readmission risk. Transition of care follow-up required within 48 hours of discharge.	03/06/2026
Active	Medication Flag — Drug interaction detected	Potential moderate interaction identified between Fluconazole and Atorvastatin (increased risk of rhabdomyolysis). Prescribing physician notified 02/05/2026; awaiting medication adjustment confirmation.	02/05/2026
Active	Social Risk — Food insecurity identified	SDOH screening on 02/18/2026 revealed member is skipping meals 2-3 times per week due to financial constraints. Referrals to Alaska Food Bank and Community Action Program submitted. Care manager should verify resource engagement at next contact.	02/18/2026

Auth ID	Type	Service	Provider	Status	Start Date	End Date
AUTH-2024-1201	Outpatient	Cardiac Stress Test	Dr. Michael Park	Approved	03/01/2024	03/31/2024
AUTH-2024-0987	Outpatient	Diabetes Education (4 sessions)	Alaska Diabetes Center	Approved	01/15/2024	07/15/2024
AUTH-2024-0855	DME	Continuous Glucose Monitor	MedEquip Alaska	Pending Review	03/10/2024

info No open complaints for this member.

Complaint ID	Category	Description	Filed Date	Status	Resolved Date
CMP-2023-0412	Access to Care	Difficulty scheduling cardiology appointment	09/15/2023	Resolved	10/01/2023

Packet ID	Type	Created Date	Created By	Status
PKT-2024-0233	Welcome Packet	01/20/2024	Jennifer Reyes, RN	Sent
PKT-2024-0456	Care Plan Summary	02/15/2024	Jennifer Reyes, RN	Sent

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Single Screen ScriptMember Name: AM2 Test

Script Name : Health Risk Assessment Script Score : 21.721000 Score Received : 15.817000 edit upload edit_note image print

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1Do you give permission to discuss your personal health information with the healthcare team?

Yes, I give permission

No, I do not give permission

Care Notes

2Do you give permission to share the results of this assessment with your doctor?

Yes, please share with my doctor

No, do not share

Care Notes

OOI

3Who is filling out this questionnaire?

Care Notes

4Is the race listed on your profile correct?

Yes, it is correct

No, it needs to be updated

Care Notes

5Is the ethnicity listed on your profile correct?

Yes, it is correct

No, it needs to be updated

Care Notes

7Have you visited the Emergency Room in the last 6 months?

Yes

Care Notes

8Have you been admitted to the hospital in the last 6 months?

Yes

Care Notes

9Are you currently taking any prescription medications?

Yes

Care Notes

10Do you have trouble paying for your medications?

Yes, it is sometimes difficult

Care Notes

11Do you have a doctor that you see regularly (a Primary Care Provider)?

Yes

Care Notes

12Have you seen your regular doctor in the last 12 months?

Yes

Care Notes

13Do you have any concerns about your eyesight or hearing?

Yes

Care Notes

14Have you fallen in the past 12 months?

Yes

Care Notes

15Do you feel safe where you live?

Yes, I feel safe

No, I have some concerns

Care Notes

16Over the last 2 weeks, how often have you felt down, depressed, or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Care Notes

17Over the last 2 weeks, how often have you had little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

Care Notes

18Do you use any tobacco products (cigarettes, vaping, chewing tobacco)?

Yes, I currently use tobacco

No, I do not use tobacco

I used to, but I quit

Care Notes

19How often do you drink alcohol?

Never

Once or twice a month

About once a week

Every day or almost every day

Care Notes

20Do you need help with everyday activities like bathing, getting dressed, eating, or getting around?

Yes, I need some help

No, I can manage on my own

Care Notes

21Can you get to your doctor appointments without difficulty?

Yes, I have reliable transportation

No, getting there can be hard

Care Notes

22In the past year, have you worried about having enough food to eat?

Yes, this has been a concern

Care Notes

23Do you have a living will or advance directive that explains your wishes for medical care?

Yes, I have one

No, I do not have one

I am not sure

Care Notes

24Would you like to learn about programs in your community that could help you, like meal delivery, senior centers, or support groups?

Yes, I would like more information

No thank you

Care Notes

25Is there anything else you would like to talk about with your care team?

Yes, I would like someone to call me about my medication costs

No, I am all set for now

Care Notes

Any New Drug Sensitivity or Reaction Communication Impairment Date Of Birth Last Immunization Date And Type Last Preventive Screening Date And Type Next Doctors Appointment Date and Reason Preferred Time Of Call Primary Caregiver Name And Phone Number Update Alternate Email Update Primary Email Update Primary Phone

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Member Name

AM2 Test

Activity Type

Health Risk Assessment

Script

Health Risk Assessment

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Member Name:
AM2 Test

DOB:
01/01/2001

Address:
123 Main Street

City:
N/A

State:
N/A

Zip:
N/A

Primary Phone:
N/A

Alternate Phone:
N/A

Cell Phone:
N/A

Language:
N/A

Payor:
Active

Care Staff:
Beatrice Kanya

Priority:
N/A

Activity Type:
Assessment- HRA

Scheduled Date:
3/25/2026 08:10:00

Scheduled Duration:
00 Hrs: 30 Mins

Custom Field Example
Yes

Mandatory Due date
03/18/2026

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