SNBC INSTITUTIONAL CARE COORDINATION DOCUMENT (ICCD) · 2018-10-08 · 1 SNBC INSTITUTIONAL CARE...
Transcript of SNBC INSTITUTIONAL CARE COORDINATION DOCUMENT (ICCD) · 2018-10-08 · 1 SNBC INSTITUTIONAL CARE...
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SNBC
INSTITUTIONALCARECOORDINATIONDOCUMENT(ICCD)*FieldswithasterisksarerequiredforMMISentry
*ClientLastName: *ClientFirstName: *M.I.:
*BirthDate: *PMINumber UCareIDNumber:
Address: Phonenumber: Facility:
PrimarySpokenLanguage: *ReferralDate *LTCCCTY:
UCM
*ActivityTypeDate(dateofassessment) *ActivityType
*COS *COR *CFR
*LegalRepStatus–Adult(age18orolder)
LegalRepName: LegalRepContactInfo:
*PrimaryDiagnosisName: *DxCode:
*SecondaryDiagnosisName: *DxCode:
*IsthereahistoryofaDDDx?☐Y☐NIfso,whatisthedx?
*IsthereahistoryofaMIDx?☐Y☐NIfso,whatisthedx?
*IsthereahistoryofaBIDx?☐Y☐NIfso,whatisthedx?
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*Whowaspresentatscreening?(morethanonecanbeselected)
☐01–Client☐02–Family☐03‐LTCCconsultant
☐ 04 ‐ Social worker
☐ 05 ‐ Public health nurse
☐ 06 ‐ Hospitaldischargeplanner☐07‐Qualifiedmentalretardationprofessional☐08‐Qualifiedmentalhealthprofessional
☐09‐NFstaff☐10‐Primaryphysician☐11‐Homecareorcommunitybasedserviceprovider☐ 12 –Advocate☐13‐Conservator/Guardian☐14‐Consultingphysician☐15‐ICF/MRstaff ☐ 16 ‐ Servicesforchildrenwithhandicaps
☐17‐Casemanager☐18‐Legalcounsel☐19‐Healthplancoordinator
☐20–Ombudsman☐21–RRS☐22‐Interpreter,English☐23‐Interpreter,ASL
☐98–Other,pleasespecify:
*Screening&AssessmentInformation
*AssessmentResultsandExitReasons *EffectiveDate
*ProgramType *CDCS *Ismemberonawaiver?☐Yes☐No
28‐SNBC ☐Yes☐No Type: WaiverCM’scontactinfo:
*ReasonsforReferral: *CurrentLivingSituation: *CurrentHousingType:
*DressingHow well are you able to manage dressing? By dressing, we mean laying out the clothes and putting them on, including shoes, and fastening clothes. Would you say that you:
*GroomingHow well are you able to manage the grooiming activities such as combing your hair, putting on makeup, shaving and brushing your teeth? Would you say that you:
*BathingHow well can you bathe or shower yourself? Bathing or showering by yourself means washing all parts of the body including your hair and face. Would you say that you:
*EatingHow well can you manage eating by yourself? Eating by yourself means drinking, eating and cutting most foods on your own. Would you say that you:
*BedMobilityHow well can you manage sitting up or moving around in bed? Would you say that you:
*TransferringHow well can you get in and out of a bed or chair? Would you say that you:
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*WalkingHow well are you able to walk around, either without any help or with a cane or walker, but not including a wheelchair? (Independence in walking refers to the ability to walk short distances around the house. Independence in walker does not include climbing stairs.) Would you say that you:
*EmotionalHealthHow would you rate your emotional health?
*ToiletingHowe well can you manage using the toilet? Would you say that you:
*SubjectiveEvaluationofHealthOverall, would you rate your physical health as excellent, good, fair, or poor?
PreventativeCare(checkallservicesyouhavereceivedinthepastyear)
☐ Flu Vaccine
☐ Annual Physical
☐ Mammogram (women)
☐ Cervical Cancer Screening (women)
☐ Prostate Cancer Screening (men)
☐ Colonoscopy
☐ Glaucoma Screening
*HearingHow is your hearing?
*Communication
How well would you say that you are able to communicate your needs or concerns to providers (for example, in‐home providers, medical providers, mental health providers)?
Howconfidentareyouthatyoucantalktoyourdoctorormentalhealthprovideraboutyourconcernsevenwhenheorshedoesnotask?
*VisionHow is your vision?
*PhoneCalling
Do you need assistance with making a phone
call?
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*ShoppingDo you need assistance when you go shopping
for food and other things you need?
*MealPreparationDo you need assistance in preparing meals for yourself?
*LightHousekeepingDoyouneedassistancewithlighthousekeeping,likedustingorsweeping?
*MoneyManagementDoyouneedassistancewithimportantpaperworksuchasMedicalAssistancerenewals?
*TransportationDoyouneedtransportationassistancewithanyofthefollowing:Medical,Dental,BehavioralHealthappointmentsorobtainingmedicationsatthepharmacy?
Whatmodeormodesoftransportationdoyourelyonmostoften?(checkallthatapply)
☐Ownvehicle
☐Publictransportationorbus
☐Specializedtransportation
☐Other
*FallsHaveyouexperiencedanyfallsinyourhomeorwhileoutinthecommunity?
Comments:
*Hospital
Inthepastyear,haveyoustayedovernightorlongerinahospital?
☐ Yes–howmanytimes?Why?
☐No
Inthepastyear,didyougotoahospitalemergencyroom?
☐Yes–howmanytime?Why?
☐No
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ProviderInformation/PlanofCare
ReviewofmostrecentMDorNPnursinghomevisitand/orannualPCPvisit.Dateofvisit: AncillaryCareProvidersseeninthelastyearasappropriate: Podiatry Dental Vision Audiology Psychiatry OtherNotes: ComprehensivePlanofCareReviewed: Multi‐Disciplinary Holistic PreventiveinFocus Member/FamilyParticipation Psychosocial Behavioral Environmental NutritionalConcerns‐Wtlossorgain PainManagement SkinIntegrity UtilizesFacilityServices Member/Family ReviewedCarePlanGoals Reviewedbarrierstogoals(ifany) ADL’s/IADL’sNotes: LevelofCareAppropriate? Yes No Ifno,alternativeservicesHomeandCommunityBasedServices(HCBS)addressed. Isthememberabletoorwishtomovebacktothecommunity? Yes NoNotes:
MembersoftheInterdisciplinaryCareTeam(ICT)