DELAWARE DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH DSAMH BEHAVIORAL HEALTH LONG TERM CARE SYSTEM ELIGIBILITY DETERMINATION REVIEW ANNUAL RE-DETERMINATION APPLICATION DSAMH ELIGIBILITY AND ENROLLMENT UNIT Ken Donovan, Director 14 Central Ave. New Castle, DE 19720 302/255-9453 (voice) 302/255-4448 (fax) Ken.Donovan@state.de.us 41.24.0 10.11.05 Page 1 of 9 I. DEMOGRAPHIC AND BACKGROUND INFORMATION 1. Enrollee’s Name: (Last) (First) (M.I.) 2. Enrollee’s MCI #: _______________ Date of Birth: ____/_____/_____ 3. Current CCCP Provider: _________________________________________ 4. Date of Re-Determination Request: _____/_____/_____ 5. Date of enrollee’s admission to current provider: ____/____/____ 6. Current Resident Type: .. Private Residence – Unsupervised .. Private Residence – Supervised .. Adult Foster Care .. Group Setting - Supervised .. Boarding House .. Group Setting – Unsupervised .. Other Institutional Setting .. Nursing Home .. Homeless .. Other 7. Street Address: City: State: Zip Code: Home Phone: Work Phone: 8. Medicaid #: _________________ Medicare#____________________ Other Insurance (Specify)_______________________________________ 9. Does the enrollee have a representative payee? _____Yes ____No If yes, the payee is: _______________________________________________________ 10. Reason for Re-determination (check all that apply) Annual RE-certification_________ Change in level of care________ 11. Name of Employee Completing and Submitting the Re-determination Request: Print Name ________________________ _ Signature ____________________________________________________________ _ Title: ____________________________ Credentials1: Organization: Address: Phone # Fax # __________________________ 1 According to the CCCP Certification Standards, a Clinician must complete the Comprehensive Medical/Psychosocial Evaluation. 41.24.0 10.11.05 Page 2 of 9 II. DIAGNOSIS A. PSYCHIATRIC EVALUATION AND DIAGNOSIS (DSM-IV-TR) Update this section, based on the DSAMH-required annual psychiatric evaluation. Either complete this section or attach a copy of the Psychiatric Evaluation itself. (If attaching the Psych Eval, please ensure that narrative of clinical symptoms and conditions justifying diagnosis is complete) Diagnosis must have been rendered within the past 30 days. For Axes I & II, indicate primary and secondary diagnosis and the justification for the diagnosis Primary and Secondary Diagnosis Axis I: Clinical Disorder Check One (Axis I or II) to indicate PRIMARY DIAGNOSIS Code _____________ [ ] _____________________________________________ Code: ____________ [ ] _____________________________________________ Code: ____________ [ ] _____________________________________________ Please describe the clinical symptoms and conditions that justify the diagnosis indicated. Axis II: Personality Disorders/Mental Retardation Code _____________ [ ] _____________________________________________ Code: ____________ [ ] _____________________________________________ Code: ____________ [ ] _____________________________________________ Please describe the clinical symptoms and conditions that justify the diagnosis indicated. Axis III: General Medical Conditions (ICD-9-CM name) Use additional space if needed. Code: ____________ ____________________________________________ Code: ____________ ____________________________________________ Code _____________ ____________________________________________ Code: ____________ ____________________________________________ Code: ____________ ____________________________________________ Please describe the clinical symptoms and conditions that justify the diagnosis indicated. 41.24.0 10.11.05 Page 3 of 9 Axis IV: Psychosocial and Environmental Problems (Check and Describe): ( ) Problems with primary support group (specify) ( ) Problems related to the social environment (specify) ( ) Educational problems (specify and indicate the highest grade completed) ( ) Occupational problems (specify) ( ) Housing problems (specify) ( ) Economic problems (specify) ( ) Problems with access to health care (specify) ( ) Problems related to interaction with the legal system/crime (specify) ( ) Other psychosocial and environmental problems (specify) Axis V: Global Assessment of Functioning Scale: Current: Highest level in the past year: Diagnostician: Psychiatrist who performed the evaluation and formulated the diagnosis: (Print Name) Phone # Date of Diagnosis: Signature: 41.24.0 10.11.05 Page 4 of 9 B. Substance Abuse Rule Out • Has a substance abuse diagnosis been specifically ruled out as either a primary or secondary diagnosis? Yes ___ No ___ • If yes, please indicate the basis for the rule out: • If a substance abuse diagnosis has not been ruled out, a recent addictions assessment completed by a clinician must be attached to this form. The clinician’s credentials must meet those specified in the CCCP Certification Standards. “Recent” is defined as having been completed within the past 90 days. If a substance abuse diagnosis has been ruled, please indicate the basis for this: III. CURRENT CLINICAL NEEDS AND FUNCTIONAL IMPAIRMENT Describe the enrollee’s clinical needs, symptomatology and/or functional impairments that continue to present obstacles to his/her rehabilitation and recovery. The narrative must be personalized for the client being described; do not repeat the pre-printed statements from the LOCUS submission on this client. Describe the client’s current clinical profile only; ‘current’ is defined as the last year. Within the narrative, indicate all significant changes that have occurred during the past twelve months and that impact the client’s treatment. LOCUS Domain 1: Risk of Harm LOCUS Domain 2: Functional Impairment LOCUS Domain 3: Medical/Addictive/Psychiatric Co-Morbidity LOCUS Domain 4: Current Recovery Environment (Level of Stress/Support) 41.24.0 10.11.05 Page 5 of 9 LOCUS Domain 5: Treatment and Recovery History (Please address both treatment and recovery specifically) Please indicate the enrollee’s psychiatric hospitalization experience during the past year. Either complete this form or attach your agency’s form that provides the same information. DATES INPATIENT PROVIDER FROM TO LOCUS Domain 6: Engagement IV. REHABILITATION AND RECOVERY PLAN AND PROGRESS 1. CURRENT REHABILITATION AND RECOVERY PLAN (Treatment and Support) a. What does the enrollee describe as his/her personal recovery goals? (If possible, use the client’s own words in this answer.) b. For each of the following domains, briefly describe the rehabilitation/recovery plan and progress made during the past year: i. Personal Independence (i.e. financial, health management, sobriety) Recovery Plan: __________________________________________________________________ Progress Made: __________________________________________________________________ 41.24.0 10.11.05 Page 6 of 9 ii. Relationships (i.e. social supports, family) Recovery Plan: __________________________________________________________________ Progress Made: __________________________________________________________________ iii. Living Arrangement (i.e. housing situation) Recovery Plan: __________________________________________________________________ Progress Made: __________________________________________________________________ iv. Education/Employment/Activity Recovery Plan: __________________________________________________________________ Progress Made: __________________________________________________________________ c. Please describe the illness management and recovery strategies that are being taught to the enrollee: d. Please describe the self-help and peer support components of the rehabilitation and recovery plan: e. Based on the progress made during the last year, how will the rehabilitation and recovery plan change for the upcoming year: 41.24.0 10.11.05 Page 7 of 9 2. SERVICE UTILIZATION IN RELATIONSHIP TO THE REHABILITATION AND RECOVERY PLAN a. Please indicate the average number of weekly CCCP contacts made with the enrollee during the past three months (other than medication administration): ____ 3 or more weekly ____ 1 or 2 weekly ____ 1 every two weeks ____ 1 per month Location of most interactions with the enrollee: ____ at agency ____ in community Please indicate other behavioral health treatment services the enrollee has received over the past six months Service Provider Frequency b. Please indicate the average number of weekly CCCP contacts planned to be made with the enrollee during the next three months (other than medication administration): ____ 3 or more weekly ____ 1 or 2 weekly ____ 1 every two weeks ____ 1 per month Expected location of most interactions with the enrollee: ____ at agency ____ in community Please indicate other behavioral health treatment services the enrollee will be receiving during the next six months Service Provider Frequency 3. MEDICATION MANAGEMENT a. Enrollee’s current access to Medications .. Medication obtained directly by enrollee (e.g. pharmacy, mail order) and stored at home .. Medication delivered by CCCP .. Daily .. Two to Three Times per Week .. Weekly .. Every Two Weeks .. Monthly b. Describe the plan for medication self-management and the specific steps being taken to achieve it. 41.24.0 10.11.05 Page 8 of 9 V. SUMMARY OF NEEDS AND SERVICE JUSTIFICATION Please summarize the enrollee’s recovery support needs for the next year and explain why CCCP services are required to meet them. If making a Diagnostic exception to the Eligible Mental Health Diagnosis criteria, please describe the reasons why consumer requires current level of care. 41.24.0 10.11.05 Page 9 of 9