Long Island BHM Initial 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:
Admission Date:
Admit Time:
DIAGNOSIS:
Primary Axis 1:
Primary Axis 2:
Primary Axis 3:
Axis 4 (Check all that apply):
None
Housing Problems
Problems related to interaction with legal
system/crime
Other psychosocial & environmental
problems*
* Details if Other:
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Type of Service:
Contact Phone #:
Mental Health Inpt
Substance Abuse Detox
Substance Abuse Rehab
Secondary Axis 1:
Secondary Axis 2:
Secondary Axis 3:
Axis 5:
Educational Problems
Occupational Problems
Problems with Primary support group
Financial Problems
Problems with access to health care services
Problems related to social environment
Unknown
*Please note: For items with a choice of only “yes” or “no”, blanks will be recorded as “no”.
Beneficiary Name:
Beneficiary Medicaid ID:
Primary Precipitant (Check only one):
Adjustment due to relocation
Financial crisis/job loss
Treatment non-adherence
(Other than medications)
Relationship conflict/loss
Legal problems
Occupational/school
performance/behavioral
problem
Death or serious medical
condition of a loved one
Police/emergency detention
Provider Name:
Parent-child conflict
Reaction to serious medical
condition (self)
Currently intoxicated/in
withdrawal
Reaction to medication
Medication non-adherence
Unable to care for self
Other**
Physical/sexual/emotional abuse
or trauma
**Details if Other:
Is this first episode psychosis?
Yes
No
For Mental Health admissions –
Was substance abuse a significant factor contributing to this admission?
Yes
For Substance Abuse admissions –
Did a comorbid Mental Health condition play a significant role in contributing to this admission?
No
Yes
No
FOR READMISSIONS ONLY: For readmissions the readmission was attributable to (check all that apply)
Previous provider did not offer referral
Uncontrolled acute symptoms on discharge
Beneficiary refused referral
Lack of transportation to outpatient level of care
Beneficiary failed to link with next level of care provider
Financial barriers to follow-up care
Disengaged from post-discharge treatment
Poor motivation for treatment
Appropriateness of level of care referred
Distance to outpatient level of care provider
Medication non-adherence
Delay in appointment with outpatient provider
Lack of post-discharge medication
Beneficiary not in agreement with plan
Loss of housing/unstable housing
Physical health issues complicated ability to follow discharge plan
Substance use/abuse
Planned readmission from medicine
Inadequate discharge supports offered
Medication treatment refractory
New external stressors
Previous discharge on 72 hours letter
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*Please note: For items with a choice of only “yes” or “no”, blanks will be recorded as “no”.
Beneficiary Name:
Beneficiary Medicaid ID:
Provider Name:
Where was beneficiary living prior to this treatment episode? (Check only one)
Correctional facility
OPWDD Developmental Center
Nursing Home or health related facility
Private Psychiatric Hospital
SUD Inpatient Rehabilitation
Article 28 Hospital
State Psychiatric Center
DOH Adult Home
OCFS Institutional Setting for Youth
OCFS/ACS/DSS Community Residential
(Residential Treatment Center or OCFS
Program (Family Foster Care Group Home,
Juvenile Justice Facility)
Therapeutic Foster Care)
CD Housing – Recovery Home – Agency
MH Housing – Community Residence (Single
Supervised
Room Occupancy)
MH Housing – Apartment Program A
MH Housing – Apartment Program B
(supportive)
(supported)
MH Housing – Residential Care Center for
Children and Youth RTF
Adults (RCCA)
Other***
*** Details if Other:
Did the beneficiary have case management services in place at the time of admission?
If Yes – has the case manager been contacted by the hospital during this admission?
Yes
Yes
Homeless- Shelter
Homeless- Street
OASAS/SUD Community Residence
OPWDD Community Residence
CD Housing – Sober Housing – NOT Agency
Supervised
MH Housing – Community Residence
MH Housing – State Operated Community
Residence (SOCR)
Private Home or apartment
No
No
FOR MENTAL HEALTH ONLY: Beneficiary was ADMITTED under which legal status:
Involuntary -- 2 Physician Certificate (Section 9.27)
Involuntary -- Emergency (Section 9.39)
Involuntary -- Director of Community Services or Designee (Sec 9.37)
Voluntary -- Section 9.13
Informal -- Section 9.15
Is the beneficiary enrolled in a Health Home?
Yes
No
Was the current or prior MH Outpatient provider contacted?
Was the current or prior SA Outpatient provider contacted?
Was the current physical health provider contacted?
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Name of Health Home:
Phone #:
Yes
No
Not applicable (No service/claims received within past 6 mos.)
Yes
No
Not applicable (No service/claims received within past 6 mos.)
Yes
No
Patient does not have primary care provider
*Please note: For items with a choice of only “yes” or “no”, blanks will be recorded as “no”.
Beneficiary Name:
Beneficiary Medicaid ID:
Provider Name:
Is this beneficiary currently under an AOT order?
Yes
No
If no, does beneficiary meet criteria for AOT?
Yes
No
If yes, has an application been submitted?
Yes
No
If yes, date of application:
If no, why not?________________________________________
Was a SPOA application submitted?
Yes
No
If yes, date of application:
If yes, Service requested in SPOA application (Check all that apply):
Housing
Family Support Services
ACT
Targeted Case Management (ICM/BCM/SCM)
Health Home
Was a referral to Case Management made outside of the SPOA process?
Yes
Date of application:
If yes, Response Date:
Was Case Manager assigned?
Yes
No If yes, date case manager assigned:
Home and Community Based Services Waiver
Youth Residential (CRTF, CR)
No
Estimated discharge date:
Is beneficiary medication treatment refractory upon admission (inadequate treatment response despite adherence with medication at therapeutic does)?
Yes
No
Unknown
Did non-adherence to psychotropic medication contribute to the present admission?
Yes
No
Unknown
If yes, please check the box that best describes the type of psychotropic medication non-adherence that led to this admission:
Refused treatment altogether
Unintentional medication non-adherence
Partial non-adherence (altering dose, skipping
(unable to obtain refills, substance relapse,
doses)
etc.)
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*Please note: For items with a choice of only “yes” or “no”, blanks will be recorded as “no”.
Beneficiary Name:
Beneficiary Medicaid ID:
Provider Name:
Please check the box(es) that best describes the primary reason(s) for medication non-adherence in this beneficiary for this admission:
Does not understand illness or purpose for
Does not perceive benefits from the
Experienced intolerable side effect(s) from
medication treatment
medication(s) prescribed prior to admission
medication
Felt condition was sufficiently improved such
Active substance use sufficient to impair
Stigma of taking psychotropic medication
that medication treatment was no longer
consistent adherence to psychotropic
needed
medication
Medication regimen was cost-prohibitive
Absence of regular outpatient treatment
If medication non-adherence was a primary or contributing precipitant for admission, please select any of the following strategies you are employing to
improve adherence in the future (check all that apply):
Simplify medication regimen (e.g., fewer
Substituting medication more tolerable to
Substituted medication compatible with
medications, less frequent dosing)
beneficiary
beneficiary preference
Substituted medication compatible with
Direct involvement of family in provision of
Establishment of direct measure methods (pill
coverage formulary
medication
counting, blood levels)
Implementation of motivational interviewing
Referral to case management services
Application for Assisted Outpatient Treatment
Arrangement of home-based psychiatric care
Date Completed:
Page 5 of 5
Form completed by:
*Please note: For items with a choice of only “yes” or “no”, blanks will be recorded as “no”.