Phc Care Transitions Program Patient Screening Form (Page 2 of 2) in pdf

Patient Name:________________ DOB: ____________ Date of Eval:_____________

Subtotal A:_____

B. Medical Record Review

From prior page

a. Chronic Physical Health Diseases

i. ESRD or Stage IV CKD or severe ARF

_____ 4 points

ii. COPD, Chronic Liver dz, metastatic CA, CHF

_____ 3 points each

iii. Diabetes Mellitus, CVA with residual deficit

_____ 1 point

b. Number of Outpatient Medications: _____ (Include vitamins)

i. 6-10

(NOTE: if using inpatient med list,

_____ 1 point

ii. 11-16

subtract 2 meds to estimate

_____ 2 points

iii. 17+

number of outpatient meds)

_____ 4 points

c. Problem medications:

i. Warfarin, other anticoagulant (except ASA alone)_____ 1 point

ii. Insulin

_____ 1 point

iii. Digoxin

_____ 1 point

iv. Other new cardiac medications

_____ 1 point

d. Functional status

i. Wheel chair bound

_____ 2 points

ii. Other ambulation impairment

_____ 1 point

iii. Severe hearing or vision impairment

_____ 1 point

e. Mental Health/substance use diagnosis/neuro

Subtotals

i. Schizophrenia/Bipolar disorder

_____ 3 points

A:___

ii. Depression/anxiety

_____ 1 point

B:___

iii. Chronic pain

_____ 1 point

C:___

iv. Heavy alcohol use

_____ 3 points

D:___

v. Active other substance abuse

_____ 2 point

Total:____

vi. Moderate to severe dementia

_____ 1 point

Subtotal B:_______

C. Recent patient history

a. Prior readmission (within 30 days of discharge)

i. This hospitalization is a readmission

_____ 5 points

b. Other Hospitalizations in past 6 months (excluding any readmission)

i. Each hospitalization

_____ 2 points each

c. ED visits in last 6 months: (Total:_____)

i. >5

_____ 3 points

ii. 3-5

_____ 2 points

Subtotal C:_______

D. Environmental characteristics (Based on Visit to Patient/Hospital)

a. Family support system

i. Homeless or unstable housing

_____ 6 points

ii. Lives alone at home

_____ 3 points

iii. Caregiver with limited capacity

_____ 3 points

iv. Discharged to SNF for reconditioning

_____ 2 points

v. Limited nearby family/friends

_____ 2 points

vi. Other undefined psychosocial risk factor

_____ 3 points

b. Health Literacy

i. Very low health literacy

_____ 3 points

c. Quality of baseline hospital to PCP handoff (Protective effect)

i. PCP rounded on patient in hospital

_____ -1 points

ii. Excellent PCP communication with hospitalist

_____ -1 points

d. Advanced Care planning before enrollment (Protective effect)

i. POLST indicates comfort care only

_____ -2 points

Subtotal D: ______

Phc Care Transitions Program Patient Screening Form Page 2

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