Attachment J HIV Referral - Acuity Scale.pdf

Acuity Scale – HIV Referral

DOT=Direct Observation Therapy ǀ MoCA=Montreal Cognitive Assessment (optional) ǀ ADL=Activities of Daily Living (e.g. bathing, toileting) ǀ IADL=Instrumental ADL (e.g.

laundry, shopping) ǀ PES=Psych Emergency Services ǀ OI=Opportunistic Infection ǀ ART=Anti-Retroviral Treatment ǀ HUMS = High Utilizer of Multiple Systems rev 5-17-17 To request an electronic version of this form, please email Andy.Scheer@sfdph.org Page 1 of 2

Please complete to the best of your ability, based on your experience with the client Ct Name: DOB:

Level 3 - Intensive Need Mobile Medical; HHOME;

Health at Home

Level 2 - Moderate Need Intensive Case Management; HOT

Level 1 - Basic Need Centers of Excellence

Level 0

Self-Management Panel Management

Brief Comments Use referral form for elaborate comments

M e d ic a l

C a re a n d T r e a tm e n t A d h e r e n ce

C a re

E g a g em en t Unable to tolerate 4-walls clinic or has received Denial of Service from >1 clinic

Severe physical illnesses w/o capacity for Tx engagement

Rarely able to tolerate 4-walls clinic w/o an escort and/or redirection

Multiple physical conditions w/ low

Tx engagement

May self-direct to drop-in clinic

Engages in 4-walls clinic w/ intensive appt. reminders

(multiple calls, texts, emails)

Engages w/ clinic to address physical conditions

Engages in clinic w/ standard appt reminders only

(phone, text, email)

Engages independently to address physical conditions

C u rr en t H ea lt h S ta tu s VL>40 and CD4<200

ART: refuses or not taking

OI’s w/i last month

Hospitalized w/i last 30-days

High Risk Pregnancy

VL>40 and/or CD4<350

ART: Refuses, not taking, or needs strong adherence support (eg: DOT)

OI w/i last 6-mo

Hospital w/i last 6-mo

Pregnant

VL>40 or Hx of detectable

VL since ART first initiated

ART: taking, may need adherence support

No Hx of OIs w/i last 6-mo

No acute medical issue w/i last 6- mo

Virally suppressed

ART: taking consistently

No Hx of OIs w/i last 12-mo

No acute medical issues w/i last 12-mo or greater

C h ro ic

Il ln es s

> 2 visits to ED w/i 30-days

Palliative care or Hospice

1-2% high utilizer

> 2 visits to ED w/i 60-days

Not flourishing medically in current level of care

3-5 % high utilizer

1 visit to ED w/i 90-days

Stable medically with support of wrap-around care

Past 1-5 % high utilizer

0 visit to ED w/i 180-days

Empowered for self-care of chronic illness

No Hx of high utilizer

F u n ct io n

P h y si ca l o g n it iv e

Despite accommodations persistent inability to follow through d/t cognitive or physical impairment

Impulse control or decision-making impairing health and multiple life Fx

Dementia

MoCA < 17

Frequent inability to follow through d/t cognitive or physical impairment

Impulse control or decision-making impairing 1 or more life Fx

MoCA 18-22

Occasional inability to follow through d/t cognitive or physical impairment

MoCA 22-26

No Impairment

MoCA >26

R x

A d h er en ce

Misses doses daily

Requires DOT

<30% med adherent

Not taking ART

Misses doses weekly

New to ART or lifesaving regimen

30% to 60% med adherent

Misses doses monthly

Missed treatment or Rx refill w/i last 90 days

60% to 90% med adherent

Rarely misses a dose

H o u si g

H u si n g S ta tu s a n d

H o u si n g R ea d in es s Lives in a place not meant for human habitation (street, car, park, etc.) AND is unable to negotiate for self in that environment

Critical unmet ADL/IADL needs;

major health or safety hazards in current housing

Expected to be released from incarceration, placement, or long term care facility w/i next 3-mo

Faces imminent eviction

Lives in a place not meant for human habitation AND able to negotiate for self in that environment

Requires assistance managing ADLs and/or IADLs

Lives in a shelter, transitional/ temporary housing or is doubled-up

Released from incarceration or long term care facility w/i last 6-mo

Chronic challenges maintaining housing

At risk of eviction

Lives in permanent or stable/safe housing but needs wrap-around assistance to remain housed

May require minor assistance managing ADLs or

IADLs

Couch surfing or hotel hopping

Resides in stable, affordable and appropriate housing with no issues that impact housing retention in the last 365-days

Does not require help managing ADLs or IADLs

Attachment J

Acuity Scale – HIV Referral

DOT=Direct Observation Therapy ǀ MoCA=Montreal Cognitive Assessment (optional) ǀ ADL=Activities of Daily Living (e.g. bathing, toileting) ǀ IADL=Instrumental ADL (e.g.

laundry, shopping) ǀ PES=Psych Emergency Services ǀ OI=Opportunistic Infection ǀ ART=Anti-Retroviral Treatment ǀ HUMS = High Utilizer of Multiple Systems rev 5-17-17 To request an electronic version of this form, please email Andy.Scheer@sfdph.org Page 2 of 2

Please complete to the best of your ability, based on your experience with the client Ct Name: DOB:

Level 3 - Intensive Need Mobile Medical; HHOME;

Health at Home

Level 2 - Moderate Need Intensive Case Management; HOT

Level 1 - Basic Need Centers of Excellence

Level 0

Self-Management Panel Management

Brief Comments Use referral form for elaborate comments

B e h a v io r a l

H e a lt h

M H

C re

E g a g em en t

Unable to tolerate 4-walls clinic

Severe Mental Illness with no provider or tx engagement

Denial of Service at mental health center

Unable to tolerate 4-walls clinic w/o an escort and redirection

MH diagnosis with no current health provider or inconsistent tx engagement

Needs face to face appt reminders or navigation

MH diagnosis w/ consistent treatment engagement

Attends MH appointments w/ standard reminders

No indication of need for

MH care or need for help engaging in Tx cu te P sy ch

I ss u e s Psych hospitalized w/i last 30-days

Imminent danger to self or others or grave disability

Psychosis with high risk of decompensation

Presence of psychosis w/ command auditory hallucinations

Presented to PES or psych hospitalized w/i last 90-days

Reports thoughts of harm to self/others but contracts for safety

Exhibits erratic behavior

Limited insight into negative impact of MH Sx on other areas of functioning

Severe Mental Illness, no psych hospitalizations w/i 6-months

Need for additional mental health support or regular check-in with mental health clinician

No PES contact or psych hospitalizations w/i 1-year or more

No current acute psych issues ro n ic I ll n es s > 2 visits PES in the past 30-days or

1-2% HUMS

MH has severe impact on health care engagement

No insight into negative impact of personality d/o on life functioning

> 2 visits to PES in the past 60-days or 3-5 % HUMS

MH has major impact on health care engagement

Limited insight into negative impact of personality d/o on life functioning

1 visit to PES 90 days or past 1-5 % HUMS prior year

Seeks MH Recovery

Empowered for self-care

Regularly engages in MH care lc o h o l

D ru g U se

Abuse or dependence that has severe impact on health

Not engaged in Sub Use Tx

>2 ED visits for drugs/ETOH w/i 30 days

IVDU with health consequences

Current or recent use that sometimes interferes with health

Loosely engaged in Sub Use Tx

>2 ED visits for drugs/ETOH w/i 6-mo

IVDU and uses clean needles

Current or recent use that does not interfere with health

Engaged in Sub Use Tx and need for additional support

SU d/o in full remission

No current or past issues with substance use

Engaged in recovery with no indication of need for additional support se M g m t.

se

M g m t.

N ee d s Acute support needed w/ financial, legal, nutritional, and/or life skills

No income or benefits

IPV, declines support

Complex coordination between multiple providers and agencies

Substantial support needed w/ financial, legal, nutritional, and/or life skills

Income/benefits are inadequate

IPV, accepts support

Active coordination between multiple care providers

Would benefit from linkage to services to address basic needs

Income/benefits occasionally inadequate

Occasional coordination between providers

No current or recent legal issues

Has steady income;

manages all financial obligations

Rarely needs coordination between providers

N v ig a ti

S y st em S u rf in g a d ea lt h l it er cy

No access to safety net programs which impacts health

Cognitively impaired or severe system trauma

Demonstrates no understanding of illness, treatment, or risk reduction

Inconsistent follow-up and routinely needs assistance to stay engaged in care

Challenges that limit ability to follow-up with appointments

Demonstrates minimal understanding of illness, treatment or risk reduction

Occasionally needs assistance to stay engaged in care

Can make their own appointments

Demonstrates basic understanding of health issues

Consistent and reliable access to and engagement in care

Demonstrates solid understanding of health issues