Return all Applications by faxing to SWCMHS/CR&SP at 203-579-7439
Instructions:
Please complete the entire application if you are referring an individual for residential support services at the Group Home (GH), Supervised, or Supported level of care. If a question does not pertain, please mark as n/a rather than leaving it blank.
The application has four parts to it: an informational portion, an independent living skills screen, a level of care request and the release of information form.
It is recommended that the referring provider complete the independent skills screen prior to requesting a level of care determination. Residential support services are aimed at providing oversight, case management and rehabilitative skill building in areas that individuals evidence functional skill deficits that prevent them from living more independently. The funded residential support services are not aimed at addressing clinical needs or providing more traditional outpatient behavioral health care services.
The independent skills screening should be completed in partnership with the individual and a person who knows the individual’s rehabilitative strengths and needs best. If the referring provider has a current or updated functional assessment (completed in the last 90 days) that is approved by the agency of the referring provider, it may be substituted for the skills screening. All referrals for residential support must be accompanied by a skills screening or functional assessment before the referral can be forwarded to a residential provider for consideration.
After completion of an evaluation of rehabilitative needs, please review the level of care guide. The level of care guide contains a brief description of each of the levels of residential support available in the residential Managed Service System.
Check the level of residential support that is most appropriate to the individual’s current presenting needs. Please be sure to complete the rational for the requested level of care and the person’s reasons and interest in receiving residential support. These two sections are very important in making a good match between the person’s needs and the level of residential support available within the provider system.
Finally, on the last page prior to the enclosed DMHAS Release of Information is a list of programs at the different levels of care and their geographic locations. Please enclose a completed release of information for any program at the requested level of care that is in the person’s preferred geographical location.
Do not hesitate to contact Mildred Daniels at 203-579-7392 or for questions or follow-up regarding referrals to any provider within the Managed Service System in Region 1.
Client Name (Print) Client Signature Date
______
Referring Clinician Agency Telephone
______
Referring Clinician email address
______
Clinical Provider Telephone
______
□ Check if Applicant Receives DMHAS Funded Services.
I. Personal Information: MPI# ______
Name: Date of Birth: Age:
Address: Telephone #: ( )
(Best contact address or address where mail is sent)
Town: Zip:
Social Security # Veteran: Yes ____ No
Gender: Marital Status: ______No. of Children:
If applicable, does applicant have custody of children: ______(Y/N or N/A)
Primary Language: ______
II. Personal Finances:
Income: Y ___ N ___ Pending ___ (Please identify if answered Y or pending)
SSI $______per month SSDI $______per month
DSS $______per month SAGA $______per month
Other (annuity etc.) $______per month Employment $______per month
Total Monthly Income $ ______
Entitlement/Insurance Information (please specify amount and complete in full):
Medicaid #:
Medicare (circle) A or B #: Effective Date:
Private Insurance Company Name and Policy Number:
Are there any outstanding debts? Indicate Amount in space provided:
UI electric ______Gas ______Oil ______
Cable ______Phone ______Credit Card ______
Bank ______Medical ______Other ______
Security deposit loan ______
III. Contact Information:
Emergency Contact: Relationship:
Address:
Phone Number: Home: ( ) Work: ( )
Community Case Manager: Phone #: ( )
Psychiatrist: Phone #: ( )
Therapist: Phone #: ( )
Medical Physician: Phone #: ( )
Conservator: (of person) Phone # ( )
Address
Conservator (of finances) Phone #: ( )
Address
IV. Current Medical/Psychiatric History:
A. Psychiatric: Must be completed by Psychiatrist, Clinician or Case Manger
DSM – V Diagnosis:
______
______
______
______
______
B. Current Medications: Focus on medication related to psychiatric and major medical conditions (include PRNs).
MEDICATION / DOSE, ROUTE, FREQUENCY / MEDICATION / DOSE, ROUTE, FREQUENCY /Yes No
C Has the individual been psychiatrically hospitalized in the past 2 years?
If yes, describe precipitants:
D. Safety Information
Please indicate responses by checking any boxes that apply.Current is defined as behavior occurring in the past 60 days. / Current
(past 60 days) / History
Violent, homicidal, or threatening behavior or thoughts?
Aggressive, agitated or impulsive verbal or physical behaviors?
Fire setting behavior?
Behavior that resulted in a criminal prosecution?
Sexually, inappropriate behavior that poses risk of dangerousness?
Victim of a sexual assault?
Paranoid beliefs or delusions, or command hallucinations that could lead to harming others?
Dangerous behavior or harmful consequences related to non-adherence or failure to take psychotropic medications?
Current / History
Non-adherence with treatment for a serious medical condition?
Living with the risk of domestic violence or perpetuator of domestic violence?
Self-injurious or suicidal statements or actions?
Significant life stressors?
Please explain any item(s) checked:
E. Does client have a history of alcohol or substance abuse? Yes ___ No ___ If yes, please complete
the table below
DRUG / AMOUNT/ FREQUENCY / LAST USED / AGE OF FIRST USE /Alcohol
Amphetamines
Cocaine/Crack
Hallucinogens
Marijuana/Hash
Tranquilizers
Heroin
Barbiturates
Inhalants
Sedatives
Nicotine
Other
Please indicate the dates of last sobriety ______
Has client ever been in SA treatment? Y___ N___ (identify)
Inpatient Detox. Outpatient Detox. Residential AA/NA or other self
V. Please complete this additional medical information
1. Has the individual been medically hospitalized in the past 2 years? No Yes
If yes, for what medical condition(s)? ______
______
______
2. List allergies, seizure history, special diet, special medical concerns ______
______
______
______
3. Has the person ever had hepatitis? No Yes If so, when? ______
Medication, if treated:______
4. Has the person been tested for TB? No Yes If so, when? ______
Results? ______Medications: ______
5. Date of last physical? ______
6. Individual is able to self-administer medications (check one) w/out supervision w/ supervision
VI. Collateral Agencies:
Please list any other providers (nursing, vocational, educational , etc.) currently working with the applicant:
NAME / AGENCY / PHONE / SERVICESPROVIDED /
VII. Education and Employment History:
Highest Grade Achieved: ______History of Special Education _____ (y/n)
Title of last 2 jobs held and the date of employment:
1). Title of Job Held: ______Date of Employment ______
2). Title of Job Held: ______Date of Employment ______
VIII. Housing
Is Applicant Willing to Live with Roommates? ______(y/n)
Current Living Situation: please check only one.
Independent Housing w/support Group Home/Half-Way House
Hospital/Institution Correctional Facility/Jail
Nursing Home Lives w/Family/Friends
Lives Alone Homeless Shelter
Street/Car/Abandoned Building TRP
Independent Living Skills Screening
Instructions: Please complete the skills screening using the scoring system outlined below. It is suggested that the screening be completed with the person who is being referred for residential support services in partnership with someone who knows the individual best.
4=with maximum assistance or prompting
3=with moderate assistance or prompting
2=with minimal assistance or prompting
1=performs independently
To compute the Overall Score for each Domain
1. multiply the number of checks in each column by the numeric value associated with the column
2. Add the scores of each of the columns together to computer the overall score for each domain
Money Management4 / 3 / 2 / 1
Has an understanding between luxuries and necessities (food,clothing,housing)
Can write checks/make withdrawals & deposits/record transactions
Can manage own money and pay bills
Can make out and maintain a budget
Can apply and maintain entitlements
Column Scores
Overall Score =
Food Management
4 / 3 / 2 / 1
Uses proper hygiene before eating or preparing foods
Able to shop for groceries and basic needs
Can fix a meal for self
Can use cooking utensils and appliances safely
Recognizes signs of spoilage in food
Can follow cooking instructions for food preparation
Consumes sufficient nutritional food
Can store food and leftovers properly
Column Scores
Overall Score =
Self-Care
4 / 3 / 2 / 1
Showers or baths regularly
Brushes teeth regularly
Dresses in clean clothing
Can wash clothes properly
Can structure daily activities
Can access community resources for basic needs
Column Scores
Overall Score =
Home Management
4 / 3 / 2 / 1
Can wash dishes properly
Regularly disposes of garbage/waste
Obtains needed household supplies (cleaning/paper goods)
Can complete routine home repairs
Can interact with landlord appropriately
Can identify housing that is within budget and meets current needs
Understands the rights of other tenants regarding property and noise
Column Scores
Overall Score =
Safety
4 / 3 / 2 / 1
Recognizes and responds to emergencies
Knows common dangers in the home
Understands common dangers in the community
Keeps household and possessions secure
Knows how to access emergency telephone numbers
Knows how to access emergency food & shelter
Understands basic fire prevention
Can check smoke detector and replace battery
Can lock/unlock doors and windows
Can contact utilities if power or heat goes out
Column Scores
Overall Score =
Health
4 / 3 / 2 / 1
Can obtain medical insurance/benefits
Can access emergency health care
Can recognize the symptoms of common health problems
Can care for self through a minor illness
Makes and keeps dental appointments
Makes and keeps medical care appointments
Can read a prescription label correctly
Aware of STD’s and their prevention
Can take prescribed medications regularly
Can explain the purpose of prescribed medications
Can explain to others any experienced mental/physical symptoms
Knows who to contact if injured or sick
Column Scores
Overall Score =
Interpersonal and Coping Skills
4 / 3 / 2 / 1
Can ask for help and knows who to contact in difficult situations
Can resolve conflict w/ others w/out becoming too aggressive/passive
Can identify relationships that could be potentially hurtful or dangerous
Can identify and express personal needs and feelings
Knows how substance use effects mental and physical wellbeing
Column Scores
Overall Score =
Other
4 / 3 / 2 / 1
Can use public transportation
Can call a taxi
Responds to messages or calls
Participates in activities with others
Shows respect for other people/property
Column Scores
Overall Score =
Computing the Total Score: Enter the Overall Score for Each Functional Domain in the corresponding box below. Compute the Total FA Score by summing the overall scores across the different domains.
Functional Domain / Overall ScoreMoney Management
Food Management
Self-Care
Home Management
Safety
Health
Interpersonal Skills
Other
*Total Score =
Total Functional Assessment (FA) Scores and Levels of Care
Individuals with Total FA Scores in the ranges noted below should be referred to the corresponding level of care.
· Total FA Scores ranging between 232 and 174 to either the MRO Residential Rehabilitation or the Supervised LOC
· Total FA Scores in the 173 to 116 range to the Supervised or Supported LOC.
· Total Scores in the 115 to 58 range to the Supported LOC.
Please review the Level of Care Guide for Residential Services that follows to determine which level of support is most appropriate for meeting the referred individual’s current needs.
Level of Care (LOC) Guide for Residential Support Services
Choose the most appropriate level of care to meet rehabilitative needs of referred consumer. Residential support services are designed to address rehabilitative versus clinical needs. The housing that is available at each level of care is transitional.
1. MRO Residential Rehabilitation (formerly known as Group Homes): □
Psychiatric Rehabilitation
· Goal - Assist individuals with serious and persistent mental illness with significant functional skill deficits to achieve their highest degree of independent functioning and recovery.
· Target Population- Individuals with significant skill deficits in the areas of self-care, independent living and illness-management as a result of their psychiatric disability and have the ability to benefit from intensive rehabilitative skill building. Individuals that require intensive oversight but have limited ability to benefit from rehabilitation should not be referred to this LOC.
Eligibility Criteria
1. Individual must be a voluntary participant
2. Primary diagnosis of a psychiatric disorder and functional impairment not solely a result of pervasive developmental disorder or mental retardation
3. Has Medicaid
4. Requires non-hospital, 24 hours, 7 day/week, supervised community based residence
5. Can participate in at least 40 hours of rehabilitation services monthly and has the cognitive ability to benefit from skill teaching
6. Services are “medically necessary” and are ordered by a clinical provider with one of the following credentials LCSW, APRN, M.D., Ph.D.
7. Admission will need prior authorization by DSS and will require on-going extended stay authorization from LMHA and managed care company; Value Options
2. Supervised LOC: □
Non-hospital, Community based residence, congregate or apartment setting
· Goal – To promote recovery, avoid relapse, maintain community tenure and prepare individual for more independence level of functioning in the community. The staffing level at the Supervised LOC is the same as that offered at the MRO Residential Rehabilitation LOC, which is 24 hours a day; 7 days a week. The scope of rehabilitative services is similar but less intensive than services at the MRO LOC.
· Target Population: Individuals with skill deficits that prevent them from living independently in the community but still require significant residential oversight and supervision with less intensive rehabilitative programming.
Eligibility Criteria
1. Absence of imminent danger to self or others
2. Skills deficit in key areas of independent living
3. Requires access to staff 24 hours/7 days per week
4. History of medication non-compliance
5. Individual could benefit from 4 – 8 hours of rehabilitative services weekly.