The following categories should be included and can be used to format your own case management admission assessment form:

Patient Information:

• Patient demographic information

Admission Information:

• Admission information including:

- Admit date

- Admit diagnosis

- Admitting service

- Attending physician

- Admit source

Financial Information:

• Financial information:

- Insurance

- Plan number

- Medicaid eligibility

Spoken Language(s)

Source of Admission:

• Admitted from:

- Acute rehab

- Ambulatory surgery

- Another acute care facility

- Behavioral health

- Emergency department

- Home

- Home with home care

- Long-term care

- MD office or clinic

- Sub-acute

Significant prior medical history:

- Angioplasty

- Behavioral health

- Substance abuse

- Blindness

- Coronary artery bypass graft

- Coronary artery disease

- Cancer

- Cardiomyopathy

- Congestive heart failure

- Chronic obstructive pulmonary disease

- Deafness

- HIV / AIDS

- Hypertension

- Pacemaker

- Paraplegic

- Quadriplegic

- Renal failure

- Stroke

- Vent dependent

- Other

- None

Mental status prior to admission:

- Alert

- Not alert

- Confused

- Oriented x 1

- Oriented x 2

- Oriented x 3

Ability to make needs known:

- Able

- Unable

Living arrangements:

- Adult home

- Apartment

- Assisted living

- Group home

- Homeless

- House

- Naturally occurring retirement community

- Nursing home

- Shelter

- Stairs

- Elevator

- Other

• Lives:

- With adult children

- With dependent children

- Alone

- With other family

- With spouse/significant other

- Domestic partner

- Other

• Support system:

- Name

- Phone number

- Relationship

• Can patient return to prior living arrangements?

- Yes

- No

Activities of daily living:

- Dependent

- Independent

• Assistive device:

- Yes

- No

• Which assistive device:

- Cane

- Oxygen

- Walker

- Other

Prior resource use:

- Children’s services

- Adult services

- Adult day care

- Behavioral health services

- Dialysis center

- Home healthcare services

- Infusion therapy

- Meals on Wheels

- Medication assistance program

- Nonmedical home care

- Support group

- Health home

- Medical home

- House calls

- Other

- None

Does patient have a primary care provider?

- No

- Yes

PCP Name

Address

Phone number

Social Work triggers:

- Abuse — Domestic violence

- Abuse and/or neglect of a child

- Abuse and/or neglect of elder/Adult

- Abuse — sexual assault

- Adjustment to illness/difficulty coping

- Alcohol abuse

- Behavioral management problems

- Crime victim

- Cultural and/or language issues

- Drug abuse

- Ethical concerns

- Family concerns and/or conflicts

- Guardianship

- Homeless requesting intervention

- Hospice placement

- Inadequate social support

- Inadequate financial support

- Long-term care placement

- Major illness causing lifestyle change

- Multisystem trauma

- Name of patient unknown

- Noncompliance issues

- Poor prognosis

- Shelter placement

- Uninsured

- Undocumented

- Other

- None

• Referred to social work:

- No

- Yes

Name

Contact info

Home care triggers:

• Patients requiring assessments/education relating to:

- New diagnosis

- New medications or change in medications

• Change in patient’s physical environment and/or new assistive device

• Patients with unstable disease process; cardio/pulmonary, diabetes, neurological, neuromuscular, metabolic, cerebrovascular, cardiovascular, renal, cancer, pediatric/including asthma, premature infants, psychiatric

• Patients with open wounds, VAC wound care, pressure ulcers

• Patients with ostomy, trachs, feeding tubes

• Patients with drainage tubes and catheters

• Patients requiring IV and injectable drug therapies

• Patients with recent change in functional status including, but not limited to: falls, paralysis, fractures, amputation or other physical impairment, change in custodial needs, ortho, neuro and or deconditioned diagnosis

• Patients with pain control management

• Patients with end-stage disease and palliative care needs

• Patients with new oxygen and/or nebulizer treatments

• Patients receiving any type of home care services (e.g., CHHA, LTHHCP, PCA, private care, etc.) at time of hospital admission

• Patients rehospitalized within 60 days and/or known history of repeated hospital readmissions

• Patients requiring expedited discharges (EHD/Bridge Program)