|
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
/
|
