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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)