COMMUNITY CASE MANAGEMENT SERVICE

COMMUNITY CASE MANAGEMENT SERVICE Community Case Management Service aims to enhance the quality of life of the needy elderly by providing on-going support to help them to remain autonomous in their own homes and community for as long as possible through the provision of community-based services. REFERRAL FORM This referral can be used commonly to refer a client to a Community Case Management Service Agency. Please refer to the boundary listing before selecting the agency to refer to. The respective Community Case Management Service Agency will fax an acknowledgement upon receipt of the referral. Eastern Region: MORAL CASE MANAGEMENT SERVICE Tel: 6489 0721 Fax: 6489 0723 Boundaries served: Changi, Pasir Ris, Tampines, Simei, Bedok, Chai Chee, Kembangan, Eunos, Paya Lebar, Aljunied, Marine Parade, Katong, Punggol, Jalan Kayu, Geylang, Mountbatten, Rochor, Potong Pasir, Serangoon, Serangoon Garden, Bras Basah, Little India, Lavender, Kallang, MacPherson, Kaki Bukit, Hougang, Sengkang Central Region: SWAMI CASE MANAGEMENT SERVICE Tel: 6257 6117 Fax: 6754 8443 Boundaries served: Marsiling, Woodlands, Admiralty, Sembawang, Yishun, Khatib, Yio Chu Kang, Ang Mo Kio, Thomson, Bishan, Braddell, Toa Payoh, Balestier, Novena, Newton, Orchard Road, Holland Road, Farrer Road, Bukit Timah (up to Bukit Timah Plaza) Western Region: HUA MEI CARE MANAGEMENT SERVICE Tel: 6471 6059 Fax: 6473 0565 Boundaries served: Tanjong Pagar, Telok Blangah, Outram Park, Tiong Bahru, Bukit Merah, Queenstown, Commonwealth, Buona Vista, Clementi, Alexandra, Brickworks, Bukit Ho Swee, Redhill, Tanglin Halt, Tanjong Pagar (up to Banda Street in China Town), West Coast, Jurong, Bukit Batok, Choa Chu Kang, Lim Chu Kang, Kranji Criteria for Community Case Management Service: Elderly with multiple needs (Frail, medical, social and psycho-social needs, etc) 60 years and above of any race Name of Client: NRIC No.: Client s current location: Home Hospital [ ] Ward No.: [ ] Bed No.: Client s address upon discharge: Postal Code: Contact No.: REFERRING AGENCY Referring Agency: Referring Person: Date of Referral: Designation: Tel No.: (O) (H/P) Fax: Email: This referral has been received by on Name / Designation Date / Time Page 1

CLIENT S PARTICULARS SOCIAL ASSESSMENT Name: NRIC No.: Sex: Male / Female Address: Postal Code: Tel No.: Date of Birth: Age: Race: Chinese Malay Indian Eurasian Others: Marital Status: Single Married Widowed Separated Divorced Religion: Buddhism Christianity Islam Hinduism Others: Language Spoken: Mandarin English Malay Tamil Others: Dialect Spoken: Hokkien Teochew Cantonese Hainanese Others: CURRENT LIVING ARRANGEMENT Alone With spouse With family With friend(s) With flatmate(s) With relatives (specify: ) TYPE OF ACCOMMODATION HDB rental room flat HDB purchase room flat Private Apartment / Condominium Private House (Terrace / Bungalow) Shophouse Others: Others: Lift Landing: Yes / No CURRENT SOURCE OF FINANCIAL SUPPORT Applicant s own savings ($ ) CPF Minimum Sum Savings ($ / month) Public Assistance (PA No: ) Allowances from children ($ / month) Other Sources (please specify type & amount) Means Test Subsidy ** Completed [ ] 75% [ ] 50% [ ] 25% Processing (please indicate level of processing) (please attach completed Means Test Application and all relevant documents e.g., copy of NRIC, pay slips, statutory declaration and application forms) **[Optional for Referral Agency] Gross Monthly Household Income (if no means test assessment is done) Below $500 $500 $999 $1,000 $1,499 $1,500 $1,999 $2,000 $2,999 $3,000 $3,999 $4,000 $4,999 $5,000 $5,999 $6,000 $6,999 Over $7,000 Page 2

FAMILY PARTICULARS No Name of immediate family members Relationship Age Staying with client (Y/N) Marital Status Occupation Gross Income CARE ARRANGEMENTS Does client have a main caregiver? Yes No 1. Name of Main Caregiver: Relationship: Address: Contact No.: (H) (O) (H/P) 2. Name of Next of Kin: Relationship: Address: Contact No.: (H) (O) (H/P) 3. Name of Main Decision Maker: Relationship: Address: Contact No.: (H) (O) (H/P) Is client receiving any kind of formal social services presently? No Yes (Please indicate name of agency in the space provided.) Financial Aid Counselling / Support Group Housekeeping Personal Hygiene Home Nursing / Home Medical Day Care (Social / Rehabilitation) Laundry Service Meals service Escort Service Home Modification Befriending Service Others (please specify) Page 3

SOCIAL REPORT Additional Information (please attach the following relevant document) Social Report Medical Report / Inpatient Discharge Summary PT / OT / ST Report Others Report Written By Name Designation Contact No. Page 4

MEDICAL ASSESSMENT CLIENT S MEDICAL INFORMATION List of current medical problem(s): List of past medical problem(s): Client s Medication(s): 1. 1. 1. 2. 2. 2. 3. 3. 3. 4. 4. 4. 5. 5. 5. 6. 6. 6. 7. 7. 7. 8. 8. 8. 9. 9. 9. 10. 10. 10. Drug allergy: No Yes (please specify if any) Dependency Status (Using the Residents Assessment Form, if available) Cat I Cat II Cat III Cat IV Cognitive Status (please describe) Normal Forgetful Confused Cognitively Impaired Others (please elaborate): Medical Follow-up S/N Venue Date Time Medication : Client has enough medication till next appointment No Yes Report Written By Name Designation Contact No. Page 5

MOBILITY STATUS FUNCTIONAL ASSESSMENT Ambulant and ADL independent Independent with wheelchair Bedridden Semi-ambulant with walking stick / quadstick / walking frame Wheelchair bound and need help with transfers Others: ACTIVITIES OF DAILY LIVING (ADL) Independent Minimal Assistance Moderate Assistance Explanation Transferring Bathing Dressing Grooming Toileting Able to use the toilet independently Need to use commode by bedside Needs assistance with transfers Urinary Incontinence [ ] No [ ] Yes 〇 catheter 〇 diapers 〇 urosheath Bowel Incontinence [ ] No [ ] Yes 〇 diapers 〇 continence sheet Others Feeding Able to eat orally [ ] Can feed self [ ] Needs assistance in feeding Is dependent on NG tube Special dietary requirement if any): INDEPENDENT ACTIVITIES OF DAILY LIVING (IADL) Independent Minimal Assistance Moderate Assistance Explanation Shopping Housekeeping Transportation Meal Preparation Financial Management Medication Use of Telephone Laundry Getting around outside e.g., visits to doctors Other comments Report Written By Name Designation Contact No. Page 6

RANGE OF SERVICES REQUIRED Dementia Day Care Centre Social Day Care Day Rehabilitation Centre Home Rehabilitation (CRP) Financial Aid Befriender Service Home Help Service Home Nursing / Home Medical [ ] Meals Service [ ] Change of Urinary Catheter [ ] Laundry Service Date due for changing: [ ] Housekeeping Service [ ] Feeding Tube [ ] Personal Hygiene Service Date of insertion: [ ] Escort Service (for medical appointments only ) [ ] Wound Dressing Type of dressing: Frequency of change: [ ] Injection Frequency of treatment: Home Modification (specify) Others (specify) Note : An assessment by the Community Case Manager will be conducted within 3 working days upon receipt of this form. Referral parties need only complete information,where applicable, to client. Page 7