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Participant Name
Medi-Cal ID
Assessment Date
Basic Needs
Food, Clothing, and Essentials
Food & Clothing / Essential Household Good Points
/
Able to self-sustain basic needs?
One Point
1 to 2 times per year may not have means or access?
Four Points
Requires help at least 6 times per year?
Six Points
Consistently without most basic needs?
Eight Points
Justification: Food & Clothing / Essential Household Goods
Activities of Daily Living
Activities of Daily Living Points
/
Requires no assistance?
One Point
Requires some assistance to perform 1 or more ADL?
Four Points
Requires complete assistance with ADLs?
Six Points
Requires complete assistance but receives none?
Eight Points
Justification: Activities of Daily Living
Medical Needs
Stable Health
Stable Health
/
Stable health with medical access?
One Point
Needs occasional assistance with treatment plan?
Four Points
Requires assistance with treatment or medications?
Six Points
Not accessing treatment or medication to control chronic conditions?
Eight Points
Unplanned hospitalizations/ED use in last year?
Unplanned hospitalizations/ED use in last 6 months?
Justification: Stable Health
Living Situation
Housing Stability
Living Situation
/
Has continued access to a stable community based living situation?
One Point
Occasionally needs short-term assistance with rent / utilities?
Four Points
Living in short-term, temporary housing?
Six Points
No available accessible housing to meet the needs of the participant?
Eight Points
Justification: Housing Stability
Health & Safety of Housing
Health & Safety of Housing
/
Clean, habitable apartment or house?
One Point
Housing is habitable, but poses some access challenges to the participant?
Four Points
Housing is marginally habitable and could pose a direct effect on the health and/or safety?
Six Points
Housing is completely uninhabitable and participant’s health is directly affected?
Eight Points
Justification: Health & Safety of Housing
Mental Health
Mental Health
/
No history of mental illness, psychological disorders, or psychotropic medications?
One Point
Has a diagnosed mental health disorder, but has regular and ongoing access to treatment?
Four Points
Un-stabilized mental health disorder because of non-compliance with medications, refusal or inability to participate in therapy?
Six Points
Danger to self or others without immediate intervention?
Eight Points
Justification: Mental Health
Addictions
Addictions
/
No difficulties with addictions including: alcohol, drugs, sex, or gambling?
One Point
Past problems with addiction; less than one year in recovery?
Four Points
Current addiction but is willing to seek help in overcoming addiction?
Six Points
Current addiction; not willing to seek or resume treatment?
Eight Points
Justification: Addictions
Activities of Daily Living
Food & Clothing / Essential Household Good Points
/

Care Management Acuity Assessment Tool Medical Form

Counselor

There are 2 copies in use.
Published: April 27, 2019, 11:46 p.m.
Doctor: Dr. History Physical
Rating: 0   /

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