ICCD Form Connect Products



SNBC Institutional Care Coordination Document (ICCD)*Fields with asterisks are required for MMIS entry*Client Last Name:*Client First Name:*M.I.:Click here to enter text.Click here to enter text. FORMTEXT Click here to enter text.*PMI NumberUCare ID Number:*Birth Date:Click here to enter text.Click here to enter text.Click here to enter text.Address:Referral Date:*Activity TypeClick here to enter text.Click here to enter a date.Choose an item.*When did you complete this interview?*LTCC CTY:Click here to enter a date.Choose an item.*COS*COR*CFRChoose an item.Choose an item.Choose an item.Facility (Name & Contact):SNF Admission Date:PCP (Name & Contact): Click here to enter text.Click here to enter text.Click here to enter text.Legal Rep Status – Adult (age 18 or older)Legal Rep Name:Legal Rep Contact Info:Choose an item.Click here to enter text.Click here to enter text.*Primary Diagnosis Name: Click here to enter text.*Dx Code: Click here to enter text. *Secondary Diagnosis Name:Click here to enter text.*Dx Code: Click here to enter text. *Is there a history of a DD Dx? ? Yes ? No If so, what is the dx? Click here to enter text.*Is there a history of a MI Dx? ? Yes ? No If so, what is the dx? Click here to enter text.*Is there a history of a BI Dx? ? Yes ? No If so, what is the dx? Click here to enter text.*Assessment Team (For care coordinator’s use)? 02 – Health Plan? 03 – County Subcontracting for Health PlanWhat is your current housing situation? (Required for SNBC members)? 01 - Homeless? 02 – Institutional (ICF/DD)? 03 – Institutional (Hospital)? 11 – Institution (NF/CBC)? 16 – Correctional Facility*Screening & Assessment Information *Reasons for Referral:*Current Living Situation:*Current Housing Type:Choose an item.Choose an item.Choose an item.*DressingHow well are you able to manage dressing? By dressing, we mean laying out the clothes and putting them on, including shoes, and fastening clothes. Would you say that you:*GroomingHow well are you able to manage the grooming activities such as combing your hair, putting on makeup, shaving and brushing your teeth? Would you say that you:Choose an item.Choose an item.*BathingHow well can you bathe or shower yourself? Bathing or showering by yourself means washing all parts of the body including your hair and face. Would you say that you: *EatingHow well can you manage eating by yourself? Eating by yourself means drinking, eating and cutting most foods on your own. Would you say that you:Choose an item.Choose an item.*Bed MobilityHow well can you manage sitting up or moving around in bed? Would you say that you:*TransferringHow well can you get in and out of a bed or chair? Would you say that you:Choose an item.Choose an item.*WalkingHow well are you able to walk around, either without any help or with a cane or walker, but not including a wheelchair? (Independence in walking refers to the ability to walk short distances around the house. Independence in walker does not include climbing stairs.) Would you say that you:*Emotional HealthHow would you rate your emotional health?Choose an item.Choose an item.*ToiletingHowe well can you manage using the toilet? Would you say that you:*Subjective Evaluation of HealthOverall, would you rate your physical health as excellent, good, fair, or poor?Choose an item.Choose an item.Preventative Care (check all services you have received in the past year)? Flu Vaccine: Click here to enter a date.? Annual Physical: Click here to enter a date.? Mammogram (women): Click here to enter a date.? Cervical Cancer Screening (women): Click here to enter a date.? Prostate Cancer Screening (men): Click here to enter a date.? Colonoscopy: Click here to enter a date.? Glaucoma Screening: Click here to enter a date.*HearingHow is your hearing?Choose an item.*CommunicationHow well would you say that you are able to communicate your needs or concerns to providers (for example, in-home providers, medical providers, mental health providers)?Choose an item.How confident are you that you can talk to your doctor or mental health provider about your concerns even when he or she does not ask?Choose an item.*VisionHow is your vision?*Phone CallingDo you need assistance with making a phone call?Choose an item.Choose an item.*ShoppingDo you need assistance when you go shopping for food and other things you need?*Meal PreparationDo you need assistance in preparing meals for yourself?Choose an item.Choose an item.*Light HousekeepingDo you need assistance with light housekeeping, like dusting or sweeping?Choose an item.*Insulin DependentAre you diabetic? If yes, how do you control your diabetes?*Money ManagementDo you need assistance with important paperwork such as Medical Assistance renewals?Choose an item.Choose an item.*TransportationDo you need transportation assistance with any of the following: Medical, Dental, Behavioral Health appointments or obtaining medications at the pharmacy?Choose an item.What mode or modes of transportation do you rely on most often? (check all that apply)? Own vehicle? Public transportation or bus? Specialized transportation? Other*FallsHave you experienced any falls in your home or while out in the community?Choose an item.Notes: Click here to enter text.*Hospital/Nursing HomeIn the past year, have you stayed overnight or longer in a hospital?? 00 - No? 01 - Yes – how many times? Why? In the past year, did you go to a hospital emergency room?? 00 - No? 01 - Yes – how many times? Why? *Sexual Activity Are you sexually active? (Required for SNBC members)? Y – Yes ? N – No ? C – Chose not to answerDo you have any family planning needs? (Required for SNBC members)? Y – Yes ? N – No ? C – Chose not to answerAdvance DirectivesIs there an Advance Directive or Health Care Directive in place?? Yes ? NoWas the Advance Directive/Health Care Directive discussed?? Yes? No*Assessment Results*Effective Date of AssessmentChoose an item.Click here to enter a date.*Relocation from Nursing Home*Program Type (For care coordinator’s use)If you currently live in the nursing home or ICF-DD do you want to relocate to the community?? Yes? No? Chose not to answer28- SNBCMember Chart Review Section? Reviewed Minimum Data Set (MDS) or other comprehensive health assessment: Date of last MDS: Click here to enter text.? Reviewed cognitive status: Click here to enter text.? Reviewed mood status: Click here to enter text.? Current rehab therapies/skilled services (OT, PT, ST): Click here to enter text.Notes:Click here to enter text.Provider Information/Plan of Care?Review of most recent MD or NP nursing home visit and/or annual PCP visit. Date of visit: Click here to enter a date.Ancillary Care Providers seen in the last year as appropriate: ? Podiatry ? Dental ? Vision ? Audiology ? Psychiatry ? OtherNotes: Click here to enter text. Comprehensive Plan of Care Reviewed: Click here to enter text.? Multi-Disciplinary? Holistic? Preventive in Focus? Member/Family Participation? Psychosocial? Behavioral? Environmental ? Nutritional Concerns - Wt loss or gain? Pain Management? Skin Integrity? Utilizes Facility Services ? Member/Family ? Reviewed Care Plan Goals ? Reviewed barriers to goals (if any) ? ADL’s/IADL’sLevel of Care Appropriate? ? Yes ? No? If no, alternative services Home and Community Based Services (HCBS) addressed.? Is the member able to or wish to move back to the community? ? Yes ? NoNotes: Click here to enter text. Nursing home plan of care attached in members file: ? Yes ? NoDate: Click here to enter text.Members of the Interdisciplinary Care Team (ICT)Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Additional Comments: Click here to enter text.?Assessor Signature: Date: Click here to enter a date.Assessor Name and Credentials: ?Click here to enter text.????*NPI/UMPI #: ?Click here to enter text.???? ................
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