IHealthSpot Interactive
Wooster Community Hospital Community Care NetworkScreening Identification ToolPatient’s Name:______________________________ Sex _____________ Date_________Age: ________________ DOB________________ Date of Admission_____________ Primary Physician_____________________ Inclusion Criteria*YesNoNumberCommentsAdmitted to hospital in past 6 months?Emergency room visits in past 6 months?Uses 5 or more medications?Chronic diseaseDelayed seeking carethat worsened symptoms?List chronic diseases: *If patient meets inclusion criteria, complete the remainder of this form and the supplemental Health Profile.Exclusion CriteriaYesNoCommentsEnrolled /active participant in HospiceSevere dementia-unable to participate in careMental health issues onlyNo chronic or co-morbid conditionsPrimary Care Provider Date Last Seen: _______________ Appointment Scheduled? **If no appointment /patient has not seen PCP in 1+ year/ or has no PCP then schedule or get a PCP. Background InformationYesNoCommentsConvicted of a crimeSocial-Economic YesNoCommentsFinancially solventNo discretionary resources and/ or underinsuredLow incomeNo incomePublic assistance dependent Not using public assistanceAdequate resources to cover medication costsHousing Situation (choose one)CommentsNo housing concernsBoarding homeShelter/ unsafe housingStreet/ no housingEducation Level (choose one)Comments> High schoolHigh school Some high school or GED< 8th GradeCognitively impaired Self-Health RatingGoodFairPoorUnable to respondComments Patient rates health as:Adherence Potential (choose one)CommentsFully cooperativeLimited cooperationUnable to cooperate/uncooperativeHealth Conditions / Comorbidities # Conditions Identified(see page 3) Comments Psychosocial Stressors- impacting medical outcomes # Issues Identified(see page 3)CommentsSocial Support # Issues Identified(see page 4)CommentsMedication ComplianceYesNo CommentsUnderstands how to take medicationsUnderstands purpose of medicationsRemembers to take medicationsMedication education needed Mental Health YesNoComment Diagnosis of behavioral issueHistory of behavioral issue and/or treatmentCurrent behavioral issueUnder current treatment*Medication management for behavioral issue*If yes to current treatment, who are they seeing:____________________________________________Fall RiskYesNoCommentHistory of fallsFall last month no treatment*ED/Hospitalized for fall in last 6 months*Multiple falls with injury in last year**Perform a home safety evaluationHealth Conditions / Comorbidities (check all that apply)Congestive heart failure (CHF) Diabetes , uncomplicatedCoagulopathyCardiac arrhythmiasDiabetes-complicatedObesityValvular diseaseHypothyroidism Weight lossPulmonary circulation disorderKidney disease Fluid and electrolyte disorderPeripheral vascular disorder Renal failureBlood loss anemiaHypertension controlledLiver disease Deficiency anemiasHypertension uncontrolledPeptic ulcer disease (excluding bleeding)Alcohol abuseParalysisAIDSDrug abuseStrokeLymphomaPsychosesSeizureMetastatic cancerDepressionOther neurological disordersSolid tumor without metastasis Anxiety disorderChronic pulmonary diseaseRheumatoid arthritis/collagen vascular diseaseDementiaChronic Pain Psychosocial Stressors (check all that apply)Change in personal habitsInsurancePersonal Injury/illnessChild CareLegal IssuesRelating to GodChildrenLoss of faithTransportationCurrent treatment for mental healthLoss: ___________________Work/SchoolDeath of a loved one or friendParentOther: _____________________FinancesPartnerSocial Support Needs (check all that apply)Difficulty with accessing servicesHousingMedication financial assistanceEquipment needed In home assistance Need home or community servicesFinancialLack of social supportPassportFoodLegalSafetyFood kitchenMeals on Wheels TransportationFood stampsMedical AlertOther: _________________Home Maker/Aide Medical insuranceCompleted By:____________________________________ Date:________________________References:Camden coalition of healthcare providers. (2014). Care management forms. Retrieved April / 10, 2014, Retrieved from Elixhauser, A., Steiner, C., Harris, D. R., & Coffey, R. M. (1998). Comorbidity measures for use with administrative data. Medical Care, 36(1), 8-27. ................
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