Targeted Case Management Contact Monitoring Form
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7Targeted Case Management Contact Monitoring Form
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Initial
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Scheduled Visit
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Significant Change
Participant Name ______________________________
Program________________________
Waiver Eligibility Dates _____________________ Last Four Digits of SSN XXX-XX-_______
Agencies/Services Provided in Home (based on Person Centered Service Plan-PCSP):
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Date of Contact ___________________
Type of Visit:
Home
Telephone
Start Time ________
Stop Time ________
Name of Person Contacted __________________________
Relationship to Client____________
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1. Does a home health nurse come to see you?
Yes
No
If yes, what is the name of the agency? _______________________________________________________________
What are the type, amount, and frequency of services? __________________________________________________
_______________________________________________________________________________________________
2. When was your last hospital admission? Why and how long? _____________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3. When was your last nursing home admission? Why and how long? _________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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4. Does someone help you take your medication?
Yes
No If yes, who helps you and how do they help you?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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DMS-690 (1-1-16)
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Parent category: Business