Comprehensive Case Management Reassessment
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1 Comprehensive Case Management Reassessment Reassessment Start Date: Reassessment Completion Date: Date of previous Assessment/Reassessment: Name: Client ID # Address: Phone: If Reassessment is early or late explain: Current HIV Status: Asymptomatic Symptomatic AIDS At Risk Date of most recent Viral Load: Date of most recent CD4 Count: Viral Load Test Results: CD4 Count Results: Method of Verification: Describe client s current situation: Emergency Contact: Phone # Relationship: Aware of Status? Y N Is there a Release of Information? Y N Date of Release: Address: 1
2 Does the client currently have an HIV medical care provider? Yes No HIV Medical Provider Name Full Address Phone # Date of most recent HIV medical visit Release of Information Expiration Date List all Other Service Providers that were involved in the last 180 days: Agency/Type of Service Provider Contact Phone # Date of last visit/service rendered Release of Information Expiration Date Identify Client s Collaterals/Children: *If any new children (under the age of 21) have moved into the household in the last 180 days, complete Child Assessment. Name Relationship In Household Y/N to Household Y/N Aware of Status Y/N Children s Assessment Completed Y/N Date of Assessment 2
3 NEEDS REASSESSMENT For each area, review client s current status, and comment on any changes in client s functioning, needs and resources. Where appropriate, include information about the family support system. Comment on all areas checked and identify progress on goal areas for the previous reassessment period. Provide a brief summary for each section. * = not previously addressed; client not ready; in process; or, other with detailed information. HEALTH CARE Primary Health Care Provider Is client keeping appointments with primary care provider? Y N Inconsistent : Means of Verification: Current Hospital Preference: Complementary/Alternative Therapies Clinical Trials TB Testing/Treatment OB/GYN Identify Provider: Date of most recent OB-GYN visit: Date of most Recent Pap Smear: Pap Smear Results: Is Client Pregnant? Yes No Due Date: If yes, is client receiving prenatal care? Yes No If yes, has ARV Therapy been discussed? Yes No Family Planning STD Testing/Treatment 3
4 HEALTH CARE continued Hepatitis C Antibody Status: Positive Negative Unknown a. If antibody positive for Hepatitis C, does the client have chronic Hepatitis C? Yes No Unknown Hepatitis Testing/Treatment/Vaccination Home Care Hospice Nutrition Dental Vision Other: (Fill in spaces below) Medications Identify current medication See next page specifically for medication Does client have access to medication? Y N Inconsistent If No or Inconsistent, : Does client need education in this area? Y N : The AIDS Institute updates the following Medications Page for use in Comprehensive Assessments and Reassessments on a quarterly basis. Replace the following page with the most recent updated copy found on the COBRA website (cobracm.org) under Resource Center. 4
5 ANTIRETROVIRAL MEDICATIONS 5
6 Based on the previous medications list, is the client currently prescribed ARV therapy? Y N CLIENT ADHERENCE QUESTIONNAIRE Please ask each question and each possible response, and circle the corresponding number next to the client s answer. Then add up the circled numbers to calculate the score. 1) How often do you feel that you have difficulty taking your HIV medications on time? By on time I mean no more than two hours before or two hours after the time your doctor told you to take it. 4 Never 3 Rarely 2 Most of the time 1 All of the time 2) On average, how many days PER WEEK would you say that you missed at least one dose of your HIV medications? 1 Everyday days a week days a week 4 Once a week 5 Less than once a week 6 Never 3) When was the last time you missed at least one dose of your HIV medications? 1 Within the past week weeks ago weeks ago 4 Between 1 and 3 months ago 5 More than 3 months ago 6 Never SCORE: Good adherence (greater than 10) Poor adherence (less than or equal to 10) Discuss side effects, difficulties following regimen, and other barriers to taking medications as prescribed: Is assistance needed? Y N Identify: 6
7 Collateral (especially children) Healthcare Status/s: Current Overall Healthcare Status/Barriers: 7
8 FINANCIAL/ ENTITLEMENTS (Include $ Amounts) Food Stamps Medicaid ADAP SSI/SSD/VA Benefits Unemployment Benefits Home Relief/Safety Net TANF HASA (LDSS) Rent Enhancement Financial Management Other: (Fill in Section Below) If on MA spend down, Identify amount: Indicate methods of spend down: Current Overall Status/s: 8
9 INDEPENDENT LIVING Date of most recent home visit: Describe (permanent, transitional, etc): Appropriate/Affordable Eviction ice Owes Back Rent Housing Repairs Advocacy with Landlord Out of Pocket Rent Expense Utilities Phone Transportation Other: Current housing status: Homeless or in Temporary Shelter Inadequate and/or Unstable Adequate and Stable Comments on Current Status/Barriers: 9
10 SUBSTANCE USE Does the client have a history of problem alcohol or drug use? Yes No Is client currently using substances? Yes No (What/How Much/How Often): & Out Patient Treatment Residential Treatment MMTP (Dosage ) AA/NA Meetings DETOX le Exchange/ Harm Reduction Program Other: (Fill in section below) a. Is the client currently receiving or need: If yes to any of the above, indicate frequency: a.1. If client has been receiving outpatient drug or alcohol treatment, attendance over the past six months has been: Inconsistent Consistent (missed less than 10% of appointments) Current Overall Status/Barriers: 10
11 MENTAL HEALTH Mental health evaluation Individual counseling/therapy Family or group counseling Outpatient psychiatric services (Private PhD/MD) Inpatient psychiatric care Medication evaluation/monitoring If client has been receiving outpatient mental health care services, over the past six months client attendance has been: Inconsistent Consistent (attended over half of scheduled appointments) Is client involved in or need a Support Group? Yes No : Is client involved in any Recreational/Social activity: Yes No : Ever prescribed medication for a psychiatric/emotional condition? Currently prescribed medication for a psychiatric/emotional condition? Yes Yes No No Prescribed Medication Purpose Dosage/Frequency Last Use (approximately if in the past year) Does client report adherence to this medication regimen? Yes No Does client need referral to physician/psychiatrist regarding psychotropic medication? Yes No Current Overall Status/Barriers: 11
12 FAMILY STABILITY Children s Service s: Medical Educational Developmental Emotional Social Client/Collateral Service s: Guardianship/ Permanency Planning Child Abuse/Neglect Parenting Skills Child Care Respite Disclosure Domestic Violence Partner/Spousal ification Is client linked with support systems? Yes No Inconsistent Identify: Other: Current Overall Status/Barriers: 12
13 LEGAL Legal Rights/Discrimination Will Living Will Health Care Proxy DNR Power of Attorney Criminal Justice Parole/Probation Immigration/Naturalization Is client/family keeping legal appointments? Yes No Inconsistent Other: Current Overall Status/Barriers: 13
14 EMPLOYMENT/ EDUCATION GED/Education Job Readiness Assessment Job Training Job Placement Volunteer/Stipend Has client returned to work or joined the workforce for the first time? Yes No If yes, PT/FT (> 20h/week): Other: Current Overall Status/Barriers: 14
15 PREVENTION EDUCATION REVIEW * Discussion in all areas is required unless referral is made. Date: Topic Referral Y/N HIV TB Hepatitis (A, B,C)/Vaccines STD Safer Sex Condoms Spermicide Dental Dam Drug Use le Sharing Use of Bleach Other Harm Reduction Techniques Universal Precautions Does client report consistent adherence to safer sex/harm reduction guidelines? Yes No Inconsistent Other: Current Overall Status/Barriers: 15
16 Ability to Perform Activities of Daily Living: If Assistance is Required, Who Currently Assists? Feeding Ambulating Transferring Grooming Dressing Bathing Toileting Homemaking Financial Management Preparing Meals Nursing Home Taking Medicine Supportive Housing Grocery Shopping Traveling Using Telephone Decision Making = By Self 1 = Some Assistance 2 = Total Assistance Recommended Care Environment: Home Home with Support Other Alone Homemaking Family Personal Care Other Skilled Nursing Hospital Nursing Home Supportive Housing Hospice ADHC 16
17 Other identified client/support system service needs or issues which need to be addressed: Summary Comments/General Status of Client/Family: Indicate client s level of participation in goal achievement over the past quarter: Case Manager Signature Completion Date S upervisor Signature Approval Date 17
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