CARE MANAGEMENTPRE-ENROLLMENT (with Risk Stratification)

Client Name:______

DOB: ______Hospital Discharge Date:______

CONTACT INFORMATION

Address: ______

______

MailingAddress:

______

______

PhoneNumber: ______AlternatePhone:______

EmergencyContact: ______

Relationship: ______

PhoneNumber: ______

INSURANCE INFORMATION

MedicalInsuranceType:

□ / □ / □ / □ / □ / □
Medicare Only / Medicaid Only / Medicare/Medicaid / Private / Uninsured / Other
______

Insurance Provider: ______

HealthInsuranceMemberID#: ______

Pharmacy: ______

PROVIDER INFORMATION

PRIMARY CARE PROVIDER*:YESNO

Name: ______

Address: ______

______

PhoneNumber: ______

Date Last Seen*: ______(only for those with a reported PCP)

SPECIALTY CARE PROVIDER:

Name: ______

Specialty: ______

Address: ______

______

PhoneNumber: ______

Date Last Seen: ______

Name: ______

Specialty: ______

Address: ______

______

PhoneNumber: ______

Date Last Seen: ______

Comments:

DEMOGRAPHIC INFORMATION

Gender:

□Male / □Male-to-Female
□ Female / □Other: ______
□Female-to-Male / □Prefer not to say

Race:

□American Indian/Alaskan Native / □White/Caucasian
□ Asian / □Multi-Racial
□Black/African American / □Other: ______
□Native Hawaiian/Pacific Islander / □Prefer not to say

Ethnicity:

□Hispanic/Latino
□ Not Hispanic/Latino
□Prefer Not to Say

Marital Status:

□Single/Never Married / □Civil Union/Domestic Partnership
□ Married / □Cohabitating with Partner
□Separated / □Other: ______
□Divorced / □Prefer not to say
□Widowed

Have you ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard?

□No, I was never in the military / □No, training in the Reserves or Guard only
□ Yes, on active duty now / □Other: ______
□Yes, on active duty in the past / □Prefer not to say

Where are you living right now?*

□House/Apartment/Room / □Streets/abandoned home
□ With friend/relative / □Other: ______
□Shelter/boarding home / □Prefer not to say

EDUCATION/LITERACY

What language do you prefer?*

□English
□ Spanish
□Other Language:______

How do you learn new information best? (Check All That Apply)

□Reading it in English / □Looking at pictures while someone explains it
□ Reading it in Spanish / □Listening to someone explain new information
□Reading it in another language / □Other: ______
□Looking at pictures with words

What is the highest level of school you have completed?

□Grades 6 to 8 / □Associates Degree
□Grades 9 to 12 / □Bachelors Degree
□GED / □Graduate Degree
□High School Diploma / □Other: ______
□Some College / □Prefer not to say

Comments:

HEALTH STATUS & SUPPORT

How would you rate your health?*

□ / □ / □ / □ / □
Excellent / Very Good / Good / Fair / Poor

Do you currently have or have been told you have any of the following health conditions? (Check all that apply)*

□ Anxiety / □ High Blood Pressure
□ Asthma / □ HIV/AIDS
□ Bipolar disorder / □ Obesity
□ Cancer / □ PVD
□ Chronic Kidney Failure / □ Schizophrenia
□ COPD/Emphysema / □ Seizures
□ Dementia / □ Sickle Cell Disease
□ Depression / □ Stroke
□ Diabetes / □ Substance Abuse
□ End Stage Renal Disease / □ Thyroid Disease
□ Heart Disease / □ Other: ______

Which of the following statements fits you best in terms of health? (select best fit)*

□A) Must stay in bed all or most of the time.
□B) Need the help of another person in getting around inside or outside the house.
□C) Need the help of some special aid, like a cane or wheelchair, to get around inside or outside the house.
□D) Do not need the help of another person or special aid, but have trouble getting around freely.
□E) Not limited in any ways.
□F) Unsure.
□ G) Unable to Respond

On a scale of 1 to 5, how often does a family member(s) or friend support you with your healthcare needs?*

□ / □ / □ / □ / □ / □
1
(No one supports me) / 2 / 3
(Sometimes I get support) / 4 / 5
(I get a lot of support) / Unable to Respond

SCORING – RISK STRATIFICATION TOOL

Pre-Enrollment (Triage):

QUESTION / SCORING RULE / RESULT / PATIENT SCORE
1) Admitted to hospital in past 6 months? / 2 admits = 1 point
3+ admits = 2 points / # of admits:
2) Emergency room visit in past 6 months? / 4-5 visits = 1 point
6+ visits = 2 points / # of visits:
3) Uses 5 or more medications? / Yes = 1 point / YES NO
TRIAGE SUBTOTAL: ______

Pre-Enrollment (Bedside):

QUESTION / SCORING RULE / RESULT / PATIENT SCORE
Primary Care Provider Date Last Seen / Has not been to PCP in 1+ year = 1 point
OR
Has no PCP = 1 point / PCP Visit > 1 year
OR
NO PCP
Housing Situation / Shelter/boarding home = 1 point
Streets/abandoned building =2 points / Shelter/boarding home
OR
Streets/abandoned
Language Preference / Non-English speaker = 1 point / English
OR
Non-English
Self-rating of Health / Fair = 1 point
Poor = 2 points
Unable to respond = 2 points / FAIR POOR
UNABLE TO RESPOND
Health Conditions Reported / 2 conditions = 1 point
3-5 conditions = 2 points
6+ conditions = 3 points / # of conditions:
Mobility / “A” = 3 points
“B” = 2 points
“C” = 1 point
“G” = 1 point / Response:
Self-rating of Social Support / 1 or 2 = 2 points
3 = 1 point
Unable to Respond = 2 points / Rating:
BEDSIDE SUBTOTAL: ______

Total Risk Score (Triage subtotal + Bedside subtotal): /19

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