Community Referral For Health Home Care Management Services (Page 3 of 6) in pdf

Community Referral For Health Home Care Management Services Page 3

Risk Factors - Check All that Apply

Check Category

Detail Indicating How Referral Meets the Risk Factor

Probable risk for adverse event,

e.g. death, disability, inpatient or

nursing home admission

Lack of or inadequate

social/family/housing support

Lack of or inadequate connectivity

with healthcare system

Non-adherence to treatments or

medication(s) or difficulty

managing medications

Recent release from incarceration

Recent release from psychiatric

hospitalization

Deficits in activities of daily living

such as dressing, eating, etc.

Learning or cognition issues

Narrative

Provide any additional information that may be helpful in assignment to a care management agency:

Specify Preferred or Recommended Care Management Agency, if any:_________________________________

Contact Information for Person Completing Referral:

Name:

Title:

Organization:

Phone:

Email:

Chautauqua County Department of Mental Hygiene - Huther Doyle

Lake Shore Health Home Services - Onondaga Case Management Services

Community Referral For Health Home Care Management Services Page 3