of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) 2 (2 points) LEVEL 1 (1 point) ACCESS Describes the Client’s need and eligibility for health benefit programs and support services to assist him/her in establishing, maintaining, and participating in medical care and treatment services. MEDICAL HOME Score: Client is not engaged in medical care; OR Client is newly diagnosed with HIV and needs assistance navigating the system of care; OR Client uses the ER as primary care provider. Client has been engaged in medical care for less than 6 months; OR Client has had more than one reported ER visit in 12 months. Client is engaged in medical care more than 6 months but less than 12 months; OR Client has had at least one reported ER visit in the last 12 months. Client is engaged in medical care for 12 months or longer; and client has had no reported ER visits. HEALTH INSURANCE/ BENEFITS Score: Client is without medical coverage; OR Client is unable to pay for care through other sources and needs immediate medical assistance. Client needs assistance to complete applications for health benefits (Medicaid, Alliance, ADAP, etc.); OR Client needs directions and assistance compiling and completing health benefit documentation or application material; OR Client’s application(s) for health benefits is pending. Client has medical insurance but insurance is inadequate to obtain care; OR Client needs assistance in meeting deductibles, co- payments and/or spend-down requirements; OR Client needs significant active advocacy with insurance representatives to resolve billing disputes. Client is insured with adequate coverage to provide access to the full continuum of clinical care including dental and medication services. Client may only need occasional information or periodic review for renewal eligibility.
of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) ACCESS (continued) CULTURAL/ LINGUISTIC Score: Client is completely unable to understand or function within the continuum of care system; OR Client is in a crisis situation and in need of immediate assistance with translation services or culturally sensitive interpreters and advocates. Client often needs translation services or sign interpretation to operate within the continuum of care or to understand complicated medical concepts. Client may need infrequent, occasional assistance in understanding complicated forms; OR Client may need occasional help from translator or sign interpreters. Client has no language problems or barriers and is capable of high functioning within linguistic/cultural environments. TRANSPORTATION Score: Client has no access to public or private transportation (e.g. lives in an area not served by public transportation, has no resources available for transportation options) AND/OR Client has difficulty accessing transportation due to physical disabilities. Client has frequent access needs for transportation; OR Client has difficulty accessing transportation due to physical disabilities. Client needs occasional, infrequent transportation assistance for HIV related needs; OR Client is unable to understand bus/train schedules or how to manage bus/train transfers. Client is fully self- sufficient and has available and reliable transportation; and has no physical disabilities or physical disabilities limiting access to transportation.
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 HEALTH STATUS (continued) DISEASE CO-MORBIDITIES (e.g. HTN, DM. CHF, Hepatitis etc.) Score: Client has unmanaged acute or chronic co- morbidities. AND/OR Client is pregnant and not actively access prenatal care Client has chronic that are not well managed. Client has chronic that are manageable with minimal medical assistance. Client has no co- morbidities; OR Client has well managed chronic and does not need assistance with treatment program. ORAL HEALTH NEEDS Score: Client has no dental provider and reports current tooth or mouth pain and severe discomfort; OR Client reports or MCM observes decayed or rotten teeth; AND/OR Client reports difficulty eating difficulty or taking medication due to oral health problems. Client has no dental provider and reports episodic pain and/or sensitivity in AND/OR Client reports or MCM observes missing teeth; AND/OR Client reports episodic or moderate difficulty eating or taking medication. Client does not have a regular dentist or has not seen a dentist in more than six months; OR Client reports not practicing daily oral hygiene and/or Client dentures need adjusting but Client reports no pain or discomfort; and; Client reports no difficulty eating or taking medication. Client is currently in active dental care and has seen a dentist within the last six months; AND/OR Client reports practicing daily oral hygiene; AND/OR Client has no complaints of tongue, tooth or gum pain; and MCM observes and/or Client reports that teeth and gum are healthy.
Areas of Functioning 4 (4 points) 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) HEALTH STATUS (continued) NUTRITIONAL NEEDS Client reports severe eating problems, acute nausea, vomiting, diarrhea, and/or other physical maladies; OR Client reports or MCM observes significant weight loss in the last 3 months; OR Client has a diagnosis of wasting syndrome. Client reports chronic nausea, vomiting, diarrhea and/or other physical maladies; OR Client reports or MCM has observed weight loss in the past 6 months. Client reports changes in eating habits in the past 3 months and requests assistance with improving nutrition; OR Client has occasional episodes of nausea, vomiting or diarrhea; OR Client reports excessive weight gain in the last 12 months. Client has no current or past eating problems and does not need any nutritional intervention; AND/OR Client reports and CM has observed no weight loss or excessive weight gain; And Client reports no problems with nausea, vomiting or diarrhea.
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) 2 (2 points) LEVEL 1 (1 point) HEALTH KNOWLEDGE Describes the Client’s ability to understand his/her current health status and diagnoses as well as his/her ability to comprehend and participate in his/her own health care and treatment. HEALTH LITERACY Score: Client needs repeated oral instruction to understand health information; OR Client cannot translate even basic written prescription/health information into daily Antiretroviral therapy (ART); OR Client does not have the capacity to understand basic health or prescription information; OR Client is cognitively impaired. Client can read some health/prescription information; OR Client may need assistance to translate complicated prescription/health information into daily ART; OR Client is mildly cognitively impaired. Client can read most basic health/prescription information; OR Client may occasionally need assistance to translate changes in prescription/health information into daily ART; Client has the capacity to obtain, process and understand health/prescription information; And Client is able to manage complicated ART without additional assistance.
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) HEALTH KNOWLEDGE (continued) HIV KNOWLEDGE Score: Client exhibits no understanding of the disease (transmission, prevention and progression) and is unable to demonstrate positive health seeking behavior; OR Client has knowledge of HIV but has a religious belief that inhibits them from accepting traditional medical treatment options. Client is unable to articulate an understanding of the disease (transmission, prevention and progression) and needs information to demonstrate positive and health seeking behaviors. Client is able to articulate some understanding of the disease (transmission, prevention and progression) but needs additional information to translate knowledge into positive health behaviors. Client is able to articulate a clear understanding of the disease (transmission, prevention and progression) and is able to translate knowledge into positive health behaviors.
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) TREATMENT ADHERENCE Details the Client’s current and historical adherence to both medical care and ARV regimens; assesses any physical, environmental, and/or emotional factors that may directly impact the Client’s ability to maintain treatment adherence; and determines the level of support the Client may need to achieve levels of treatment adherence. MEDICATION ADHERENCE Score: Client reports missing doses of scheduled medication daily and is experiencing on-going barriers to adherence and has a viral load of more than 400; OR Client refuses to follow prescribed ARV medication regimen and has a viral load of more than 400; OR Client chooses herbal/alternative drug therapies despite negative health outcomes; OR Client requires professional assistance to take medication. OR Client is diagnosed, and not yet prescribed or taking medications Client reports missing doses of scheduled medication weekly and is experiencing on-going barriers to adherence and has a load of more than 400; OR Client reports choosing to engage in alternative/herbal drug and is medically stable; OR Client just starting on ARV medication regimen; OR Client’s long-term ARV medication regimen is does not appear to be effective. Client is adherent to ARV medication regimen but may need occasional assistance from MCM to maintain optimum adherence. Client is adherent to ARV medication regimen and has a viral load of less than 400; OR Reports missing no more than one (1) dose in a 30 day period; OR ARV medication is not indicated at this time. recommended
of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) 1 (1 TREATMENT ADHERENCE (continued) ADHERENCE TO APPOINTMENTS Score: Client has missed multiple scheduled appointments in last 60 days. OR Client has never attended and HIV medical appointment History of 3 or more missed appointments in the last 120 days. Client has missed no more than 1 appointment with appropriate rescheduling and appointment kept. No history of missed appointments in the last 12 months. ARV MEDICATION SIDE EFFECTS Score: Client is experiencing severe side effects with ARV medications; OR Client has been newly prescribed ARV medication; OR Client is newly diagnosed and has not yet been prescribed ARV medication. Client is experiencing mild side effects with ARV medication. Client has a recent history of side effects with ARV medication. No current report of side effects with ARV medications; OR ARV medication is not indicated at this time.
KNOWLEDGE OF HIV MEDICATION Score: Client is unable to identify his/her own ARV medications; OR Client has no knowledge of the purpose of his/her ARV medications; OR Client has no knowledge of the side effects of his/her ARV medication regimen. Client is able to identify some of his/her ARV medications but is unable to identify the purpose of the drugs; OR Client is unable to list more than 2 side effect of his/her ARV medication regimen. Client is able to identify but not name all prescribed ARV medications; and Client has some understanding of the purpose of the drugs and; Client is able to list at least 3 potential side effects of his/her ARV medication regimen. Client is able to identify and name all prescribed ARV medications; And Client understands the purpose of the drugs; and client is able to list at least 3 potential side effects of his/her ARV medication regimen. OR ARV medication is not indicated at this time.
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) 1 (1 point) TREATMENT ADHERENCE (continued) TREATMENT SUPPORT Score: Client reports no support system (no family, friends or peers); OR Client is in imminent danger of being in crisis; OR Client resists referrals and assistance with taking medication. Client reports inconsistent and/or no dependable support system; OR Client is isolated from families, social groups, and/or may be new to area; OR Client has not disclosed status to family members due to fear of stigma. Client reports gaps in availability and adequacy of support system from family and friends; AND Client is requesting additional support; AND Client has disclosed HIV status to his/her support system. Client reports strong support from family, friends and AND Client has disclosed HIV status to his/her support system. BEHAVIORAL HEALTH Details any emotional, cognitive, disordered and/or addictive behaviors diagnosed, displayed, or reported by the Client and the impact of these behaviors on the Client’s ability to collaborate with health care professionals and adhere to health care regimens. MENTAL HEALTH Score: Client expresses or exhibits behavior that indicates the Client is a danger to self and/or others; OR Client has been diagnosed with mental illness and is not in treatment. Client self-reports mental illness or history of mental illness and is in treatment but is non- compliant with following treatment prescribed. Client self-reports mental illness or history of mental illness and receives treatment and/or is evaluated consistently; and condition is stable. Client self-reports no history of mental illness and does not exhibit any behavior that may need an assessment.
of Functioning LEVEL 4 (4 points) 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) CHILDREN/FAMILIES Describes the Client’s primary, self-identified familial relationships particularly any individuals dependent on the Client for life needs; the level of support needed to assist the Client in sustaining these primary relationships; and the degree to which these relationships impact the Client’s ability to adhere to medical practices. CHILDREN Client is in advanced stage of disease and cannot provide care and/or is faced with possibility of losing children. Client needs ongoing child are or transition care and may also need assistance with permanency planning or parenting classes; OR Client has a child with special needs. Client needs assistance in getting access to permanency planning; OR Client needs assistance to disclosure HIV status to children; OR Client needs assistance with respite care/support; parenting classes Client has no children living with them; OR Client needs no assistance. DEPENDENTS Score: Client has dependent(s) living with them; AND Client is experiencing a current crisis related to dependents. Client has 3 or more dependents living with them; AND Without MCM assistance the Client may be at-risk of crisis. Client has 1-2 dependents living with them; AND Client needs minimal or occasional assistance with dependents. Client has no dependents living with him/her; OR Client needs no assistance with dependents.
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) 1 (1 point) ENVIRONMENTAL Describes the Client’s current social and physical environment; how contributing environmental factors either support or hinder the Client’s ability to maintain medical care and achieve positive health outcomes; and the level of external support needed to address critical barriers to successful outcomes. DOMESTIC VIOLENCE Score: Client reports that he/she is currently engaged in physically, sexually and/or emotionally abusive relationship and feels life is in danger of violence. Client reports that he/she has experienced domestic violence in the past 12 months; OR MCM observes visible evidence that the Client may be at risk. Client self-reports a history of domestic violence, but is not in abusive relationship; OR Client is removed from abuser. Client self-reports no history of domestic violence. LIVING SITUATION Score: Client is homeless, living in a shelter, sleeping on streets or in his/her car; OR Client is in immediate danger of becoming homeless and needs housing placement ; OR Client is unable to live independently and needs to be placed in assisted living facility. Client is in transitional or unstable housing; OR Client is at-risk of eviction, having utility(s) shutoff and/or of losing housing due to financial strain; OR Client assistance with rent/utilities to maintain housing. Client currently has adequate housing but may need occasional short-term rent or utilities assistance to remain stable. Client is in permanent housing and is not in danger of losing housing.
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) ENVIRONMENTAL (continued) FINANCIAL Score: Client has no income and cannot currently meet basic needs; OR Client needs immediate emergency intervention to address financial crisis. Client has difficulty maintaining sufficient income from available sources to meet basic needs; OR Client requires frequent ongoing referrals from MCM to stabilize income. Client’s income may occasionally be inadequate to meeting needs. Client has a steady, stable source of income and is able to meet monthly financial obligations. LEGAL ISSUES Score: Client is experiencing a crisis involving matters; OR Client is incarcerated or recently released from correctional facility; OR Client has a current or extensive criminal history; OR Client is in need of services to access health benefits. Client wants assistance completing applicable advanced directives (living will, last will, power of attorney, advanced directives) including permanency planning; and client has recent or current minor legal problems; OR Client has issues. Client wants assistance completing applicable advanced directives (living will, last will, power of attorney) and no current legal problem. Client has no recent or current legal problems; OR Client does not want assistance with or has completed all applicable advanced directives (living will, last will, power of attorney, advanced directives). Client Name: Final score: Acuity Level of need assigned: Medical case manager’s signature: ________________________ ______________ ___ Date: