CASE MANAGEMENT POLICY

CASE MANAGEMENT POLICY Subject: Acuity Scale Determination Effective Date: March 21, 1996 Revised: October 25, 2007 Page 1 of 1 PURPOSE: To set a minimum standard across Cooperative agencies regarding the frequency and duration of client contact based on an assessment of client needs. This acuity scale was developed to respond to the evolving needs of clients living with HIV/AIDS. Today, HIV/AIDS is defined as a chronic illness. As such, maintaining ongoing medical treatment becomes even more important. In addition to managing acute clinical symptoms, medical care is becoming more focused on containing the disease, slowing its progression, and managing HIV related symptoms. POLICY: Client acuity will be determined at intake, reassessment, and/or whenever substantial changes occur in a client s expressed needs. To support this shift, case managers will take a lead role to identify clients requiring medical case management. Medical case management is defined as a range of client-centered services that link clients with health care, psychosocial, and other services. The coordination and follow-up of medical treatments is a component of medical case management. These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the client s needs and personal support systems. Medical case management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments. Key activities include (1) initial assessment of service needs; (2) development of a comprehensive, individualized service plan; (3) coordination of services required to implement the plan; (4) client monitoring to assess the efficacy of the plan; and (5) bi-annual reevaluation and adaptation of the plan as necessary over the life of the client. It includes client-specific advocacy and/or review of utilization of services. Supportive services case management will also be offered to eligible clients. This service is defined as a social service that includes the provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services. Supportive services case management does not involve coordination and follow-up of medical treatments, as medical case management does. Regardless of the type of case management provided, three key elements of a case manager s role are: initially assessing the service needs of clients, developing a comprehensive, individualized service plan with clients, and coordinating services required to implement the plan. The attached acuity scale is a tool that has been developed to assist case managers in completing these tasks. Additionally, case managers will play a key role in determining the appropriate level of case management services, medical case management, or supportive services case management. This acuity scale will help case managers begin to collect information to assist in that determination. PROCEDURE: Case managers will make periodic contact with clients to assess and monitor changing needs and the utility of the service plan. Frequency and type of contact should be based on client s acuity score. Case managers will act as liaisons between clients and service providers to facilitate implementation of the

service plan. Case managers will provide supportive counseling and encouragement to clients for whom appropriate services cannot be found or have yet to be implemented. The acuity scale is much more comprehensive and detailed than the prior scale. It is organized into two parts: social service and support needs assessment (Social Determinants of Health Scale Part 1) and medical and key core services needs assessment (Clinical Acuity Scale- Part 2). The social services section, called the Social Determinants of Health Assessment, evaluates the following areas A)Legal; B) Basic Living Needs; C) Transportation; D) Culture and Language; E) Social Support; F) Risk Reduction; G) Housing and Residential Needs; H) Income & Finances and I) Family and Dependents. The medical needs section assesses: 1) Medical Care (access and adherence); 2) Mental Health service needs 3) Substance Abuse service needs; and 4) Other Clinical Needs. These forms are intended to be used with the Client Intake/Case Status Change and Reassessment tool to assist in gathering client assessment information at baseline, during ongoing client assessments, and to collect and assess eligibility information. The client intake form provides basic information which case managers should refer to when completing the acuity tool. To be effective, both parts of the acuity scale must be administered during the same session. In addition, the tools must be completed with the client to assess client-identified needs in each of these areas. FORMS: Acuity Scale Instructions Acuity Part 1 Social Determinants Scale Acuity Part 2 Clinical Determinants Scale AIDS FOUNDATION OF CHICAGO Northeastern Illinois HIV/AIDS Case Management Cooperative

Acuity Scale Instructions Part 1 Social Determinants of Health This section of the acuity scale focuses on assessment of client social service needs. The information is similar to the information that is collected at an intake assessment and/or reassessment. Case managers should administer this section of the acuity scale prior to administering the clinical indicators portion of the acuity scale (Part 2). Administering the scale in this order will help case managers build strong working relationships and help facilitate conversations with clients. It will also help case managers identify acute social service needs of the client more quickly. Finally, case managers are more familiar with assessing social services needs, which may be a more comfortable format for both the case manager and client. The scale identifies common key areas where clients may require traditional case management supportive services. Information collected in these areas will help inform individual service plans, but should not replace traditional agency service plans. Administration Case managers will analyze each social service area based on client response to the general questions asked and the specific questions in specific sections. Case managers will assign a level of service need per general area. The levels of service need corresponding with highest level of need that the client identifies. For example, if a client answers yes to a question for level 3, they are assigned a value for level 3. For sections A- F, a specific question is provided which case managers should use as a guide for asking clients. Case managers are free to use additional probing techniques to help collect information to place the client in the appropriate level. Additional information to help complete the acuity for Sections G-I can be answered based on the clients answers to corresponding sections in the Client Intake/Case Status Change and Reassessment form. Ideally, the assessment should be administered in an informal conversational interview format. For each section, there are a series of yes/no and open ended questions that correspond to different levels of service need. Case managers are encouraged to ask these questions and assign a score to the client based on the responses to the questions. Case managers will utilize this information to develop a service plan that addresses client needs as identified in the responses. Case manager clinical judgment and follow up questions to the client are encouraged to help determine the level of service need per area. The scale uses a point system to determine degree of need. Points are assigned by levels. There are four levels that have the following point breakdown: Level 1: 0 points Level 2: 2 points Level 3: 4 points Level 4: 8 points A cumulative score for part 1 is obtained by summing up the total points for each section.

QUESTION BY QUESTION GUIDE Section A: Legal This section focuses on any legal issues the client may be currently experiencing. Case managers will want to collect information on past history of incarceration and what specific need(s) a client may have in this area. The probe question is provided below: Do you have any current or recent legal issues that require additional assistance (i.e. pending cases, powers of attorney, and living wills)? Do you have all the legal documents you need to care for yourself? Also, it is important to refer to the legal section of the Client Intake/Case Status Change and Reassessment form to help identify any recent incarcerations or pending court cases. Section B: Basic Living Needs Client basic needs and level of independent functioning are assessed in this section. This section provides important information as to the client s immediate food and shelter needs. Do you have basic living needs, such as clothes, food, etc? Can you perform activities that keep you independent in your home such as bathing, grooming, dressing, cooking, cleaning, etc? Section C: Transportation This section assesses the transportation needs. It is important to determine whether transportation factors play a role in accessing medical care. What type of transportation do you currently use to get to your primary care/medical and other clinical appointments, and have you experienced any gaps? Page 4 of the Client Intake/Case Status Change and Reassessment form will help to determine eligibility of the client to receive Ryan White funded transportation services. This section of the acuity scale will help to determine the level of need for those services. Section D: Culture and Language This section assesses cultural or language barriers that may impact access to medical or social

services. Cultural barriers also include barriers clients may experience due to their sexual orientation or religious beliefs. Do you or your family have any language or cultural barriers that prevent you from identifying and accessing services? Section E: Social Support System This section focuses on client self-assessment of type and quality of social support that the client receives from family, friends or professionals to help manage and cope with their HIV. (Note: this question is different than section G which assesses their role within their family and the dependents or family responsibilities they may have). This section should also be used to identify any potential domestic violence issues facing the client. Please describe your family, friends, and loved ones and their ability to support you as you treat your HIV/AIDS. Are you currently experiencing any emotional or physical abuse from any of these individuals? Section F: Risk Reduction This section helps case managers begin to discuss risk reduction to better understand the degree to which a client may be engaging in high risk behavior. When asking this question it is important to indicate that the question pertains to a specific time period (Past Month). Case managers should try to get client to quantify the frequency rather than give simply a percentage. For example, begin the question by stating Within the last month When possible, obtain actual number. For example, if the client states 20% of the time, clarify if that corresponds with 1 unsafe sexual encounter out of five, or 2 unsafe sexual encounters out ten. The acuity defines the 20% level as mild, > 20% to 50% as moderate, and over 50% as significant. Any level of high risk sexual practices represents a need for education and prevention counseling. These levels are designed to gauge the extent of the issue to be addressed in the service plan. How often have you engaged in any behaviors that put you at risk for re-infection of HIV, infection of another STD, or has put another person at risk for contracting HIV? How many times in the past year have you been diagnosed with an STD? SECTIONS G THROUGH I THE FOLLOWING SECTIONS ARE ADDITIONAL AREAS THAT CASE MANAGERS MUST ASSESS. IN ORDER TO COMPLETE THE REMAINING SECTIONS, IT IS NECESSARY TO REFER TO THE CLIENT S INTAKE FORM AS WELL AS THE

QUESTIONS IN EACH LEVEL. EACH OF THE FOLLOWING SECTIONS CORRESPOND TO AN IDENTIFIED DATA COLLECTION SECTION OF THE CLIENT INTAKE/CASE STATUS CHANGE AND REASSESSMENT FORM. Section G: Housing and Residential Needs This section relates to acute and long-term housing needs. Information on current living arrangements is provided in Client Intake/Case Status Change and Reassessment form. Section H: Income & Finances This section assesses the client s financial needs. This section assesses income sources and need for additional benefit services to adequately support the client. Section I: Family & Dependents This section assesses whether the client has dependents or needs support to manage own dependents. This section also focuses on the client s responsibilities as a provider to his/her own family. Instructions for obtaining an overall acuity rating for Part 1 The total acuity rating is the sum of scores for sections A to I. The range of scores will be 0-72. The higher score should indicate the greatest need. After completing Part 1, case managers must then administer Part 2 of the acuity scale, Clinical Indicators.

Part 2 Clinical Determinants of Health This section of the acuity scale focuses on assessment of client clinical needs. The information is a more in depth assessment of the basic clinical information that is collected at an intake assessment and/or reassessment. Case managers should administer this section of the acuity scale after administering the social determinants portion of the acuity scale (Part 1). The clinical indicators address the core services that are identified in the Ryan White HIV/AIDS Treatment Modernization Act: medical care, substance use, mental health, and oral health. The scale identifies common key areas where clients may require case management supportive services in order to establish or maintain adherence to key clinical treatments in their HIV care. Information collected in these areas will help inform individual service plans, but should not replace traditional agency service plans. Administration Case managers will analyze each clinical service area based on client response to the general questions asked and the specific questions in specific sections. Case managers will assign a level of service need per general area. The levels of service need corresponding with highest level of need that the client identifies. For example, if a client answers yes to a question for level 3, they are assigned the point value for level three. Ideally, the assessment should be administered in an informal conversational interview format. For each section, there are a series of yes/no and open ended questions that correspond to different levels of service need. Case managers are encouraged to ask these questions and assign a score to the client based on the responses to the questions. Case managers will utilize this information to develop a service plan that addresses client needs as identified in the responses. Case manager clinical judgment and follow up questions to the client are encouraged to help determine the level of service need per area. The scale uses a point system to determine degree of need. Points are assigned by levels. Most questions have four response levels that have the following point breakdown: Level 1: 0 points Level 2: 2 points Level 3: 4 points Level 4: 8 points Some questions have a separate scoring format that is delineated on the forms and throughout the instructions. A cumulative score for Part 2 is obtained by summing up the total number of points for each section.

Section A: Medical Assessment (0 64 points) This section of the clinical acuity scale is intended to assess the level to which a client is enrolled and active in obtaining primary care and to assess any needs in this area. The clinical acuity scale Medical Assessment section is divided into 2 subsections: (A1) Access to Medical Care and (A2) HIV Medication Adherence. Section A1 assesses whether a client currently has a medical care provider, the adherence to the most recent medical visits, and frequency of missed appointments. Section A2 assesses the need for and access to HIV medications. It also assesses the degree to which a client reports being adherent to their HIV medication regiment for those clients currently prescribed and taking HIV medications. Section A1: Access to Medical Care A1a: Do you currently have a stable medical provider (Doctor, Nurse, etc) who you see for your HIV treatment? This is a yes/no question. If client responds no, you will automatically assign a score of 64 and move on to Section B (Mental Health Assessment). The rationale for assigning a score of 64 (the maximum number of points) relates to HIV being a chronic medical condition requiring ongoing primary medical care monitoring, so clients with no primary medical care currently should receive ongoing HIV medical care to monitor their HIV disease, slow its progression, and manage HIV related symptoms. Case managers should work with the client to coordinate a medical appointment within the 2 weeks following this assessment. If the client responds yes, move on to questions A1b and A1c. A yes response to question A1a is not assigned a point value. Case managers should work with the client to coordinate and monitor medical appointments. A1b: When did you last see your medical provider? There are four categories that a client can select: Within the last three months Between three and six months ago Between six months and one year More than one year ago (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) A point score, ranging from 0 to 8, is assigned based on the client response. This follow-up question to A1a, along with question A1c, provides the case manager with pertinent information as to whether the client is seeing an HIV medical provider regularly. If the client scores zero points, skip to question A2a. A1c: How many of the last three doctor s appointments did you miss excluding the most recent appointment kept? There are 4 responses a client can select from:

None One Two Three (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) NOTE: The frequency that a client should see their HIV medical provider depends on their health status (e.g. viral load levels, acute medical conditions) and current Public Health system treatment guidelines. The categories provided in the question are not intended to make any clinical assessment, but rather to provide case managers with a general indication of treatment adherence to determine need for primary care referrals. Section A2: HIV Medications and Treatment This section is intended to assess the degree to which clients who are being prescribed medications report being adherent to their prescribed HIV medication regimens. Responses in this section are weighted differently than the other sections for two reasons. First, medication adherence is an extremely important component of their overall medical care. Second, medication adherence is best viewed as a yes/no type of assessment. A client is either taking their HIV medication regularly or they are not, the degree of non-adherence is less important than the reasons for the non-adherence. A2a: Have you been prescribed medications for your HIV? This is a yes/no question and is not scored. Further information is needed to find out whether the client is not taking medication for clinically appropriate reasons or other reasons. If a client says no, ask question A2b. If a client responds yes, go to question A2c. A2b: Why are you currently not prescribed medications for your HIV? There are 4 responses a client can select from: Medical Provider says I do not need to be Medical Provider took me off my meds, or is assessing readiness I cannot get access to payment for the medications I don t want to be on medications (Level 1 =0 points) (Level 2 =2 points) (Level 3 =6 points)* (Level 4 =10 points)* *(Since medication access and non-adherence is such an important treatment component, lack of access to HIV medication or resistance to taking medication is scored at a higher level.) For those client s determined to be prescribed medications, the case manager must than administer questions A2c-A2e to assess the client s medication adherence. Assign point values based on client s responses to determine the degree of adherence. A2c: How often do you feel that you have difficulty taking your HIV medications on time? (By on time we mean no more than two hours before or after the time your doctor told you to take it.)

Never Rarely Most of the time All of the time (Level 1 = 0 pts) (Level 2 = 2 pts) (Level 3 = 4 pts) (Level 4 = 8 pts) If a client has difficulty quantifying this, ask them to give you their best guess, or respond with the first response that comes to their head. Remind them that the goal is to support adherence, not penalize non-adherence. A2d: On average, how many days PER WEEK would you say that you missed at least one dose of your HIV medications? Never (Level 1 = 0 pts) 1 3 days per week (Level 2 = 2 pts) 4 6 days per week (Level 3 = 4 pts) Every day (Level 4 = 8 pts) A2e: When was the last time you missed at lest one dose of your HIV medications? Never (Level 1 = 0 pts) More than two weeks ago (Level 2 = 2 pts) 1 2 weeks ago (Level 3 = 4 pts) Within the past week (Level 4 = 8 pts) HOW TO SCORE SECTION A Scores from section A1 and A2 are summed together to get an overall score for the medical assessment section. Scores can range from 0 to 64. The higher the score the greater the need to work with the client to ensure that they enter and remain connected with a medical care provider. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. For example, if the client indicates that they have missed doses 4 6 days in the last two weeks (a score of 4), as measured in question A2d, the case manager should probe further to reduce the barriers to adherence for this client. Section B: Mental Health Assessment (0-40 points) The purpose of this section is to: 1) assess level of emotional distress (mental health symptoms) client is currently experiencing; 2) whether that distress is affecting their ability to maintain medical care and 3) to decide whether referral to mental health services is needed. The clinical acuity scale Mental Health Assessment section is divided into 2 subsections: (B1) Access to Mental Health Care and (B2) Psychiatric Medication Adherence. Section B1 assesses whether a client currently has a mental health issue and, if the client currently has a mental health provider, the adherence to the most recent treatment visits, and frequency of missed appointments. Section B2 assesses the need for and access to psychiatric medications. It also assesses the degree to which a client reports being adherent to their medication regiment for those clients currently prescribed and taking psychiatric medications.

Section B1: Access to Mental Health Care B1a: Has your mental or emotional health ever affected your ability to complete your activities of daily living? This is a yes/no question. If client responds no, a score of zero is recorded and you skip to Section C Substance Use Assessment. If a client reports yes, a score of 8 is assigned to this question. B1b: Have you ever been treated for mental illness? This question is not assigned a point value. It just provides information that may be used for service planning. For example, a client may report no emotional distress which may be due to them seeing a mental health provider. It also seeks to predict future activities to treat mental illness, by assessing past treatment seeking behaviors. B1c: Do you currently have a counselor/psychiatrist/therapist that you see for your mental health treatment? If the client responds yes, ask question B1d. This question is not scored. B1d: How many of the last three doctor s appointments did you miss excluding the most recent appointment kept? There are 4 responses a client can select from: None One Two Three (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) This question helps assess the degree of engagement in mental health care. It may be helpful to do some probing to find out why a client may not be seeing a clinician regularly, if determined that the client is experiencing mental or emotional disruptions. Section B2: Psychiatric Medication B2a: Are you currently being prescribed medications for your mental illness? This is a yes/no question and is not scored. If no, skip to Section C Substance Use Assessment. For clients who are being prescribed medications, the case manager must than administer questions B2b-B2d to assess the client s medication adherence. Assign point values based on client s responses to determine the degree of adherence. B2b: How often do you feel that you have difficulty taking your mental illness medications on time? (By on time we mean no more than two hours before or after the time your doctor told

you to take it.) Never Rarely Most of the time All of the time (Level 1 = 0 pts) (Level 2 = 2 pts) (Level 3 = 4 pts) (Level 4 = 8 pts) If a client has difficulty quantifying this, ask them to give you their best guess, or respond with the first response that comes to their head. Remind them that the goal is to support adherence, not penalize non-adherence. B2c: On average, how many days PER WEEK would you say that you missed at least one dose of your medications? Never (Level 1 = 0 pts) 1 3 days per week (Level 2 = 2 pts) 4 6 days per week (Level 3 = 4 pts) Every day (Level 4 = 8 pts) B2d: When was the last time you missed at least one dose of your mental illness medications? Never (Level 1 = 0 pts) More than two weeks ago (Level 2 = 2 pts) 1 2 weeks ago (Level 3 = 4 pts) Within the past week (Level 4 = 8 pts) HOW TO SCORE SECTION B The maximum point score for this section is 40. Sum together scores from section B1 and B2 for a total score. Case managers should also refer back to the client intake to help inform service planning. The higher the score the greater the need to work with the client to ensure that they enter and remain connected with a mental health care provider. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. Note: There is some redundancy in client intake form and mental health assessment scale. These tools should be used in conjunction to inform the service plan. Section C: Substance Use Assessment (0 40 points) This section requires that you use information from both the substance use section of the client intake form and the questions asked here about substance use treatment history. Together this information will help you decide whether a substance use treatment referral is needed and provide information about the impact of substance use on a client s life. The clinical acuity scale Substance Use Assessment section is divided into 2 subsections: (C1) Access to Substance Use Treatment and (C2) Substance Use Medications and Treatment Adherence. Section C1 assesses whether a client currently has a substance use issue and, if the client currently has a treatment provider, the adherence to the most recent treatment visits, and

frequency of missed appointments. Section C2 assesses the need for and access to substance use medications and treatments. It also assesses the degree to which a client reports being adherent to their medication regiment for those clients currently prescribed and taking methadone or other medications. Section C1: Substance Use Access to Care C1a: Are you currently being treated for substance use? This is a yes/no question. If no, skip to Section D Other Clinical Needs. If yes, continue to question C1B. This information can be compared to the substance pattern questionnaire from the Intake/Case Status form to help inform whether or not the client has an historical or existing substance use issue. C1b: If yes, what type of treatment are you receiving? This question will help you determine the degree of substance use severity and level of support the client is seeking to address. Clients referred to more intensive substance use treatment settings usually will require more intensive and ongoing treatment. They also may be at high risk for medical treatment non-adherence. Self-Help, 12-step Outpatient Treatment Day Treatment Residential (Level 1 = 0 pts) (Level 2 = 2pts) (Level 3 = 4pts) (Level 4 = 8pts) C1c: Do you currently have a stable counselor/therapist who you see for your substance use treatment? If the client responds yes, ask question C1d. This question is not scored. C1d: How many of the last three counselor/therapist s appointments did you miss? There are 4 responses a client can select from: None One Two Three (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) This question helps assess the degree of engagement in substance use treatment. It may be helpful to do some probing to find out why a client may not be accessing their treatment regularly. This will be helpful for individual service planning. Section C2: Substance Use Medications and Treatment C2a: Have you been prescribed medications (methadone, etc.) for your substance use?

This is a yes/no question, and is most applicable to those with past or present opiate addiction. C2b: Have you missed any doses of your medication because you could not afford them or get them in any way? This is a yes/no question. A yes response is scored as 8 points, and may indicate a current need for treatment with barriers to accessing it. HOW TO SCORE SECTION C Sum the total responses to each section. The higher the score the greater the need to work with the client to ensure that they enter and remain connected with a substance use treatment provider. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. Section D: Other Clinical Needs (0 40 points) The information collected will help assess need for medical case management and informs individual treatment planning. The format for this section is different than Sections A-C as there is only one question per the five domains. In this section, it is important to assign a score for each section based on the highest level the client responds to. For each section, a general question is asked. The case manager is then provided with some examples of responses that would be appropriate for various levels and points to assign. Based on the response given, the case manager must make a clinical judgment about the appropriate level of need and assign that point value. Section D1: Knowledge of HIV Disease This section is intended to help case managers get an estimate of the client s HIV knowledge level. Based on clients responses, case managers should assign a score ranging from 0 to 8 for this section. Level 1 (0 points): Client is able to describe to their case manager: 1) that HIV/AIDS is a chronic illness; 2) requires ongoing medical care; and 3) there are available medical treatments that keep people with HIV/AIDS living longer. Case managers should ask these questions Can you tell me what CD4 T-cell count and viral load mean? Why is important to know and monitor your T-cell and viral load count? Can you tell me what highly active antiretroviral therapy (HAART)? If a client answers these questions correctly, score client as 0 in the domain. Level 2 (2 points): Client knows that s/he has a medical condition, but knows little about how the

virus affects the body. S/he also displays limited knowledge about medical treatment. The client will not be able to clearly answer the level 1 questions, but does demonstrate a basic understanding of HIV disease. Case managers should ask these questions: Do you feel your general knowledge of HIV disease is good enough that you do not need additional information? (y/n) Do you feel that you have a good understanding of the different types of HIV medications regimens? (y/n) If clients respond no, to either question, score as a 2. Level 3 (4 points): Client communicated inaccurate information about HIV disease progression. S/he is unaware how effective HIV medications can be for ongoing medical care. Case managers should ask these questions: Has anyone ever talked to you about HIV medications and how effective they are in keeping you healthy? (y/n) Do you think that because you are HIV+ positive there is no treatment that can help you? (y/n) Consider asking a true or false question from HIV educational materials you may have available at your agency. If a client responds no or continues to demonstrate inaccurate understanding, score as a 3. Level 4 (8 points): Clients is unable to answer the basic information about HIV disease (how HIV is transmitted, what HIV stands for, what AIDS stands for, etc.) Client does not know how they contracted HIV or how it spreads. Client exhibits no knowledge of HIV. Section D2: Nutrition This section assesses the need for nutritional services. The primary indicators are client selfreported physical symptoms associated with eating and digestion that interferes with day to day functioning (and potentially medication adherence). Are you having any problems with eating, weight gain, abdominal pain, nausea or diarrhea? How often do you eat? How do your prepare food? Describe a general day s eating habits. How do you manage nausea or diarrhea? Section D3: Oral Health

This section assesses the need for dental services. The primary indicator is level of pain client is experiencing and degree to which pain interferes with day to day functioning. The questioning should also address any denture needs or problems. Are you having any problems with you mouth or teeth, pain when chewing or eating, or have need for assistance with dentures? Section D4: Health Insurance & Medical Coverage Please remember to also review client responses from the Client Intake/Case Status Change and Reassessment forms prior to completing this section. How are you currently paying for your medical services and/or how are you paying for your medications? (Please refer to insurance and health coverage questions on Intake.) Section D5: Pregnancy The final section pertains to reproductive health. It is to be asked to both men and women. Case managers should adjust the wording of the question accordingly. That is, if asking the question is to a male, the question should be directed to determine if the client and his partner are currently pregnant or is planning to become pregnant. Are you currently or planning to become pregnant? If you are pregnant, was this a planned pregnancy? Are you currently receiving prenatal care? The scoring must take into account the current pregnancy status, future reproductive planning, and access to prenatal care. HOW TO SCORE SECTION D This section should be scored by summing the total of each section to obtain an overall score for section D for a total possible score of 40 points. The higher the score the greater the need to work with the client to ensure that these issues do not create barriers to clinical care. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. Instructions for obtaining an overall acuity rating for Part 2 Clinical Indicators The total acuity rating is the sum of scores for sections A through D. In prioritizing categories of need, scores in the clinical acuity scale should be addressed prior to the needs identified in the social determinants of health acuity tool, whenever possible. Social determinants that are identified as barriers to accessing clinical care should also be prioritized.