Interviewer: __________________________________________
Interview Date: ________________
CARE MANAGEMENT PRE-ENROLLMENT (with Risk Stratification)
Client Name:_____________________________________________________________
DOB: ___________________
Hospital Discharge Date:___________________
CONTACT INFORMATION
Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Mailing Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone Number: _______________________
Alternate Phone:________________________
Emergency Contact: ___________________________________________________________________
Relationship: _________________________
Phone Number: _______________________
INSURANCE INFORMATION
Medical Insurance Type:
□
Medicare
Only
□
□
Medicaid Only Medicare/Medicaid
□
□
□
Private
Uninsured
Other
____________
Insurance Provider: _________________________________________________
Health Insurance Member ID#: ________________________________________
Pharmacy: ________________________________________________________
PROVIDER INFORMATION
PRIMARY CARE PROVIDER*:
YES
NO
Name: _______________________________________________________________________________
Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone Number: _______________________
Date Last Seen*: _______________________(only for those with a reported PCP)
SPECIALTY CARE PROVIDER:
Name: _______________________________________________________________________________
Specialty: ____________________________________________________________________________
Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone Number: _______________________
Date Last Seen: _______________________
Name: _______________________________________________________________________________
Specialty: ____________________________________________________________________________
Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone Number: _______________________
Date Last Seen: _______________________
Comments:
2
DEMOGRAPHIC INFORMATION
Gender:
□ Male
□ Female
□ Female-to-Male
□ Male-to-Female
□ Other: ________________________
□ Prefer not to say
Race:
□ American Indian/Alaskan Native
□ Asian
□ Black/African American
□ Native Hawaiian/Pacific Islander
□ White/Caucasian
□ Multi-Racial
□ Other: ________________________
□ Prefer not to say
Ethnicity:
□ Hispanic/Latino
□ Not Hispanic/Latino
□ Prefer Not to Say
Marital Status:
□ Single/Never Married
□ Married
□ Separated
□ Divorced
□ Widowed
□ Civil Union/Domestic Partnership
□ Cohabitating with Partner
□ Other: ________________________
□ Prefer not to say
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
□ Yes, on active duty now
□ Yes, on active duty in the past
□ No, training in the Reserves or Guard only
□ Other: ________________________
□ Prefer not to say
Where are you living right now?*
□ House/Apartment/Room
□ With friend/relative
□ Shelter/boarding home
□ Streets/abandoned home
□ Other: ________________________
□ Prefer not to say
EDUCATION/LITERACY
What language do you prefer?*
□ English
□ Spanish
□ Other Language:______________________
3
How do you learn new information best? (Check All That Apply)
□ Reading it in English
□ Reading it in Spanish
□ Reading it in another language
□ Looking at pictures with words
□ Looking at pictures while someone explains it
□ Listening to someone explain new information
□ Other: ________________________
What is the highest level of school you have completed?
□ Grades 6 to 8
□ Grades 9 to 12
□ GED
□ High School Diploma
□ Some College
□ Associates Degree
□ Bachelors Degree
□ Graduate Degree
□ Other: ________________________
□ 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
□ Asthma
□ Bipolar disorder
□ Cancer
□ Chronic Kidney Failure
□ COPD/Emphysema
□ Dementia
□ Depression
□ Diabetes
□ End Stage Renal Disease
□ Heart Disease
□ High Blood Pressure
□ HIV/AIDS
□ Obesity
□ PVD
□ Schizophrenia
□ Seizures
□ Sickle Cell Disease
□ Stroke
□ Substance Abuse
□ Thyroid Disease
□ Other: ________________________
4
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
5
SCORING – RISK STRATIFICATION TOOL
Pre-Enrollment (Triage):
QUESTION
SCORING RULE
1) Admitted to hospital in past 6 months?
2) Emergency room visit in past 6 months?
3) Uses 5 or more medications?
2 admits = 1 point
3+ admits = 2 points
4-5 visits = 1 point
6+ visits = 2 points
Yes = 1 point
RESULT
PATIENT
SCORE
# of admits:
# of visits:
YES
NO
TRIAGE SUBTOTAL:
________
Pre-Enrollment (Bedside):
QUESTION
SCORING RULE
RESULT
Primary Care Provider Date Last Seen
Has not been to PCP in 1+ year = 1 point
OR
Has no PCP = 1 point
Shelter/boarding home = 1 point
Streets/abandoned building =2 points
PCP Visit > 1 year
OR
NO PCP
Shelter/boarding
home
OR
Streets/abandoned
English
OR
Non-English
FAIR
POOR
Housing Situation
Language Preference
Non-English speaker = 1 point
Self-rating of Health
Fair = 1 point
Poor = 2 points
Unable to respond = 2 points
Health Conditions Reported
Mobility
Self-rating of Social Support
2 conditions = 1 point
3-5 conditions = 2 points
6+ conditions = 3 points
“A” = 3 points
“B” = 2 points
“C” = 1 point
“G” = 1 point
1 or 2 = 2 points
3 = 1 point
Unable to Respond = 2 points
UNABLE TO
RESPOND
# of conditions:
Response:
Rating:
BEDSIDE SUBTOTAL:
Total Risk Score (Triage subtotal + Bedside subtotal):
6
PATIENT
SCORE
_______
/19
7