HIV Level of Care (HIVLOC)[MS1]
State Plan Personal Care/AIDS Waiver Assessment
- Participant Information
Participant Name (Last, First, MI) / DCN
MO HealthNet Enrollment Verified
Spenddown Amount
Client receives other in-home services (Consumer-Directed, Hospice, Physical Therapy, Skilled Nursing, etc.) Describe:
- Reason for Assessment
New Enrollment
Annual Update
Other:
- Assessed Needs/Level of Care
Monitoring of physical and/or mental condition
0 (PRN monitoring)
3 (minimal monitoring- at least 1x per month; stable)
6 (moderate monitoring for verified unstable health condition)
9 (maximum intensive monitoring by professional personnel)
Comments/Supporting Documentation:
Medications
0 (no prescription medications)
3 (prescription medications for stable condition)
6 (prescription medication set-ups/supervision required)
9 (multiple prescription medications with various dosages/time of administration; 9 or more prescription medications; total assistance required )
Comments/Supporting Documentation:
Treatments
0 (none)
3 (simple dressings, suppositories, compression stockings)
6 (daily dressings- ulcers, cath, ostomy care, prn oxygen)
9 (dressing changes-more than 1x/day, new/unregulated ostomy, cont. oxygen)
Comments/Supporting Documentation:
Restorative
0 (no services required)
3 (minimum services required to maintain current level of function)
6 (moderate services required to restore higher level of function)
9 (maximum teaching and/or training services required to restore higher level of function)
Comments/Supporting Documentation:
Rehabilitative(physical therapy, occupational therapy, speech therapy, audiology)
0 (no services required)
3 (minimal rehabilitation services required- 1x/week)
6 (moderate rehabilitation services required- 2-3x/week)
9 (maximum rehabilitation services required- 4 or more x/week)
Comments/Supporting Documentation:
Personal Care(Activities of Daily Living)
0 (none)
3 (minimal assistance needed; infrequent incontinence-1x/week or less)
6 (moderate assistance needed; frequent incontinence- 2-3x/week)
9 (maximum assistance needed; continuous incontinence)
Comments/Supporting Documentation:
Dietary
0 (no assistance needed)
3 (minimal assistance needed with cooking/eating orphysician ordered diet)
6 (moderate assistance needed with cooking/eating or physician ordered diet for unstable condition)
9 (maximum assistance needed with cooking/eating or physician ordered diet for unstable condition)
Comments/Supporting Documentation:
Mobility
0 (no assistance needed for transfers or mobility)
3 (periodic assistance needed for transfer or ambulation)
6 (assistance required for transfer or ambulation; mobile only with direct staff assistance)
9 (immobile; totally dependent upon staff for mobility)
Comments/Supporting Documentation:
Behavior and Mental Condition
0 (no assistance needed)
3 (periodic assistance needed; some memory lapses or occasional forgetfulness)
6 (moderate assistance needed; disorientation and/or uncooperative behavior)
9 (maximum assistance needed; experiences confusion, hostility, verbally/physically abusive, incapable of self-direction, etc.)
Comments/Supporting Documentation:
- Safety Concerns
History of violent behavior
Weapons in the home
Uncontrolled pets
Unknown/unstable persons in the home (guest, resident, etc.)
Suspicion of drug/illegal activity in the home
Physical environment unsafe (tripping hazards, fire hazard, insect/rodent infestation, etc.)
Concerns about abuse/neglect/exploitation
Unsafe neighborhood
History of falls
No telephone available/Unable to use telephone
Other:
Comments:
Discussed with client
Emergency Plan (describe):
Discussed with client
- Personal Goals(minimum of one)
1.
2.
3.
4.
- Medical Criteria (complete for AIDS Waiver only)
Multi-organ failure (ex: liver, kidney, heart, pancreas, lung)
Support to maintain vital function and/or maintain complex IV therapy, peripheral nutrition, central venous catheters, daily diabetic blood sugar tests and insulin injection
Assessment and assistance with pain control and/or pain therapy during acute and terminal phases of illness
Oversight as related to dementia, and/or severe chronic and persistent mental illness (ex: bipolar, multiple suicide attempts, schizophrenia, confusion)
Oversight related to terminal phase of illness
Licensed nursing care on a regular basis to assist in recovering from opportunistic infections and/or acute illnesses
Weekly monitoring required by a licensed nurse and/or physician in order to provide assessment for opportunistic infection (CD4/VL, signs and symptoms)
Licensed nursing care on a regular basis to assist with medication setup, adherence and monitoring for serious side effects
Monitoring and assistance to maintain safety/optimum mobility related to neurological deficits (ex: neuropathy or uncontrolled seizures)
Oversight as a result of co-morbid complications (ex: substance abuse, secondary disease processes, TB and hepatitis)
- Scoring
Level of Care Score ______ (total of points from Section C; minimum of 21 points required)
Medical Criteria Score ______(total of points from Section F; minimum of 2 for AIDS Waiver)
Refer for SPPC
Refer for AIDS Waiver
Refer to Other Program
Comments:
Revised 08/2012
[MS1]The HIV LOC is used in coordination with the AIDS Waiver Biopsychosocial Acuity Index. Both tools were developed by staff at the Missouri Department of Health and Senior Services.