Long Island BHM Discharge Clinical
Please complete this form to the best of your knowledge.
Beneficiary Name:
Beneficiary Medicaid ID:
Provider Name:
Beneficiary DOB:
Contact Name for Additional Information: Contact Phone #:
Admission Date: Admit Time: Type of Service: Mental Health Inpt Substance Abuse Detox Substance Abuse Rehab
DIAGNOSIS:
Primary Axis 1: Secondary Axis 1:
Primary Axis 2: Secondary Axis 2:
Primary Axis 3: Secondary Axis 3:
Axis 4 (Check all that apply): Axis 5:
None / Educational Problems / Financial ProblemsHousing Problems / Occupational Problems / Problems with access to health care services
Problems related to interaction with legal system/crime / Problems with Primary support group / Problems related to social environment
Other psychosocial & environmental problems* / Unknown
* Details if Other:
Actual Discharge Date: Discharge Time: Did beneficiary leave against medical advice? Yes No
County of discharge residence: Nassau Suffolk Queens Other: ______
Beneficiary Name: Beneficiary Medicaid ID: Provider Name:
Beneficiary’s residence upon discharge(Check only one):
Correctional facility / OPWDD Developmental Center / Homeless- ShelterNursing Home or health related facility / Private Psychiatric Hospital / Homeless- Street
SUD Inpatient Rehabilitation / Article 28 Hospital / OASAS/SUD Community Residence
State Psychiatric Center / DOH Adult Home / OPWDD Community Residence
OCFS Institutional Setting for Youth (Residential Treatment Center or OCFS Juvenile Justice Facility) / OCFS/ACS/DSS Community Residential Program (Family Foster Care Group Home, Therapeutic Foster Care) / CD Housing – Sober Housing – NOT Agency Supervised
CD Housing – Recovery Home – Agency Supervised / MH Housing – Community Residence (Single Room Occupancy) / MH Housing – Community Residence
MH Housing – Apartment Program A (supportive) / MH Housing – Apartment Program B (supported) / MH Housing – State Operated Community Residence (SOCR)
MH Housing – Residential Care Center for Adults (RCCA) / Children and Youth RTF / Private Home or apartment
Other**
** Details if Other:
If discharged to the community – is it the same residence as prior to admission?Yes No
Has AOT petition been filed? Yes No If yes, date: If yes, is there an outcome? Yes No
AOT petition Outcome (Check only one):
Adjourned / Denied / WithdrawnDismissed w/o Prejudice / Granted / Unknown
Was SPOA application submitted?Yes No If yes, date:
Service requested in SPOA application (Check all that apply):
Housing / Family Support Services / Home and Community Based Services WaiverACT / Targeted Case Management (ICM/BCM/SCM) / Youth Residential (CRTF, CR)
Health Home
Beneficiary Name: Beneficiary Medicaid ID: Provider Name:
Is an appointment for outpatient MH treatment part of the discharge plan? Yes No If yes, date of appointment:
If yes, is the appointment at an OMH licensed clinic? Yes No If yes, Clinic Name: Phone #:
Is an appointment for outpatient SUD treatment part of the discharge plan? Yes No If yes, date of appointment:
If yes, type of program (Check 1): Outpatient Treatment Outpt Methadone Maintenance OPCD program for Youth Intensive Residential Program
If yes, Program Name: Phone #:
Were there barriers to obtaining a timely (7 days for MH, 14 days for SA) aftercare appointment for this beneficiary? Yes No
If yes, please select the reason:
Service not available within geographic area / Transportation Issues / Funding issues
If appointment made, was case summary sent or available electronically to the aftercare provider in advance of the start date or scheduled appointment?
If yes, date sent: If no, please explain:
Is beneficiary being discharged on medications requiring prior approval? Yes No
If yes, has such authorization been obtained? Yes No
Does beneficiary have any medical problems for which a follow up appointment is recommended within 45 days of discharge? Yes No
If yes, was a follow up appointment scheduled?Yes No
If no, please explain:
If yes, date of appointment:
Is beneficiary enrolled in managed care for physical health care? Yes No If yes, MCO was contacted? Yes No
Was Beneficiary/Family/Primary Support involved in the discharge plan? Yes No
Beneficiary Name: Beneficiary Medicaid ID: Provider Name:
For Beneficiaries under 21, please note if any of the following needs were identified, and if so, are being addressed in the discharge plan:
Area of Need / Need Identified? (Y/N) / If Yes, Addressed in D/C Plan? (Y/N)Housing / Y N / Y N
Food Stamps / Y N / Y N
Educational Needs / Y N / Y N
Transportation / Y N / Y N
Parental Supervision/DSS/ACS Involvement / Y N / Y N
Is the beneficiary enrolled in a Health Home? Yes No Name of Health Home: Phone #:
Was the current or prior MH Outpatient provider contacted? Yes No Not applicable (No service/claims received within past 6 mos.)
Did the beneficiary have case management servicesin place at the time of admission? Yes No
If Yes – has the case manager been contacted by the hospital during this admission? Yes No
If Yes – has the case manager been notified of the discharge? Yes No
Readmission Risk Reduction Interventions (please check all):
Long acting injectable medication started/maintained / Clozaril / ACT/ICM/AOT referralMedication assisted treatment (methadone, Buprenorphine, Suboxone, etc.) for Substance Abuse / Med adherence monitoring system put in place (family, pill counting, supervised meds) / IDDT or referral to IDDT program
Dose regimen modified for increased adherence / Alternative medication that is more acceptable to patient provided to improve adherence / Motivational interviewing focused on adherence
Medication provided on discharge/Discharge with 30-day supply of meds / CBT focused on adherence / Peer services, bridge inpatient/outpatient
Date Completed: Form completed by:
Page 1 of 4*Please note: For items with a choice of only “yes” or “no”, blanks will be recorded as “no”.