Clinical Assessment
The information gathered in this Clinical Assessment will be used in two ways. The first is to assist the members of the Community Support Plan team to develop a comprehensive and relevant community support plan for the patient. The second is to provide information to Counties to coordinate and develop needed community resources for patients discharged from Mayview State Hospital.
The patient’s social worker is responsible for gathering the information to complete this clinical assessment. All members of the patient’s treatment team, particularly those who know the patient ‘the best’, must participate in completing this assessment so the most comprehensive and up to date clinical information is available for Community Support Plan meetings. If the patient has identified a staff member who is not an official member of the treatment team but who knows the patient well, that staff member can also be included in completing the assessment. In addition, the social worker must gather information from the assigned County and/or Provider Hospital Liaison. All parties who contribute to the assessment must sign page 2 of this document.
There are a variety of ways to collect information to
complete the Clinical Assessment. The team can meet as a whole to complete the
assessment or individual team members can complete the assessment during
‘downtime’, privately, in an office, or in a common space where the assessment
is available twenty-four seven. The only requirement is that the assessment be
completed seven (7) working days prior to the first scheduled Community Support
Plan meeting for the patient.
First Name: ___________________________ MI: ______ Last Name: ____________________________________
Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Date of birth (month, date, year): ___ ___ / ___ ___ / ___ ___ ___ ___
County of last residence: _______________________________________
Unit: _______________ Hospital Liaison: _______________________________________
Name of clinician coordinating clinical assessment: _______________________________________
Date of assessment meeting: ___ ___ / ___ ___ / ___ ___ ___ ___
Treatment team members participating in assessment:
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Signature |
Position/Role |
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1. Please identify the patient’s insurance coverage.
____Medical Assistance, if yes, provide number _____________________
____Medicare, if yes, provide number _________________________________
____Commercial Insurance, if yes, provide number ______________________
____Veterans Administration, if yes, provide number _____________________
Please identify the patient’s income source and the monthly amount. ________________________________________________________________________________________
________________________________________________________________________________________
What benefits is the patient eligible to receive in the community? ________________________________________________________________________________________
________________________________________________________________________________________
If the consumer currently has a payee, please provide name and contact
information.
________________________________________________________________________________________
________________________________________________________________________________________
If the consumer currently has a Power of Attorney, please provide name and contact information.
________________________________________________________________________________________
If the consumer currently has a Legal Guardian, please provide name and contact information.
________________________________________________________________________________________
Domain 1: Living
1. First, what town did the patient live in before coming to Mayview?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. Right before coming to Mayview, what type of place did the patient live in and whom did he/she live with?
(Do not include acute services when answering this item.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. a) The next time the patient is discharged, is there a particular neighborhood, town, or city you would recommend he/she live in? _______________________________________________________________________________________
_________________________________________________________________________________________________
b) Why? ____________________________________________________________________________________________
__________________________________________________________________________________________________
4. List residential type and level of support for the five (5) years prior to admission. Please include treatment services, case management services, housing and vocational supports, natural supports, etc. in the Community Supports column. Attach additional sheets if necessary.
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Start Date |
End Date |
Residential Type |
Who Living With |
Community Supports |
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5. Check whether you would recommend the living arrangement below for the patient and how much professional support you recommend he/she would need in the setting. Please note that ‘outpatient help’ refers to Case Management, Community Treatment Team, Psychiatry, and Rehabilitation. Answering the frequency of how much help is needed will help the team in the planning process to understand the general level of needed community supports.
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Housing Choices |
Very much |
A Little |
Not At All |
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a. Live in a house, apartment, or room by self |
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b. With: ( )Daily Outpatient Help ( ) Weekly Outpatient Help ( ) Monthly Outpatient Help ( ) No Outpatient Help |
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6. Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.
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Housing Choices |
Very much |
A Little |
Not At All |
a. Live in a house, apartment, room w/ family |
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b. With: ( ) Daily Outpatient Help ( ) Weekly Outpatient Help ( ) Monthly Outpatient Help ( ) No Outpatient Help |
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7. Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.
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Housing Choices |
Very much |
A Little |
Not At All |
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a. Live in a house, apartment, room w/roommate(s)
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b. With: ( ) Daily Outpatient Help ( ) Weekly Outpatient Help ( ) Monthly Outpatient Help ( ) No Outpatient Help |
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8. Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.
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Housing Choices |
Very much |
A Little |
Not At All |
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a. Live in a transitional rehabilitation group setting with other clients and 24/7 staff support on-site w/roommate(s)
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b. With: ( ) Daily Outpatient Help ( ) Weekly Outpatient Help ( ) Monthly Outpatient Help ( ) No Outpatient Help |
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c. How long do you think he/she needs to live here? |
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9. Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.
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Housing Choices |
Very much |
A Little |
Not At All |
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a. Live in a permanent group setting w/other clients and 24/7 staff support on-site room w/roommate(s)
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b. With: ( ) Daily Outpatient Help ( ) Weekly Outpatient Help ( ) Monthly Outpatient Help ( ) No Outpatient Help |
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10. Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.
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Housing Choices |
Very much |
A Little |
Not At All |
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a. Other (Describe)
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b. With: ( ) Daily Outpatient Help ( ) Weekly Outpatient Help ( ) Monthly Outpatient Help ( ) No Outpatient Help |
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11. If he/she shares a living space, how many people do you recommend he/she lives with in a:
a) room __________
b) apartment __________
c) house ___________
c) supervised setting __________
12. If he/she shares a living space, what age group do you recommend he/she live with? ___________________
13. Where did he/she do the best when living in the community?
_________________________________________________________________________________________
b. Why? __________________________________________________________________________________
_________________________________________________________________________________________
14. What does the patient already know that will help him/her live successfully in the community?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
15. This is the last question under housing. Check whether you recommend he/she would do better being in walking distance of each place or if it wouldn’t matter if he/she has to take a bus to get there.
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Resources/Amenities |
Able to Walk to… |
Able to Take a Bus to… |
Doesn’t matter… |
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a. See Family & Friends |
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b. A Bus Stop |
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c. Open spaces/Parks |
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d. Church, Synagogue, Mosque, etc. |
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e. Malls/shopping areas |
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f. A Food bank |
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g. A Library |
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h. A Grocery Store |
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i. A Pharmacy |
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j. A Post Office |
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k. Museums |
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l. Sport/fitness centers |
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m. Drop-in Centers |
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p. Dentist |
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q. Mental Health Clinic |
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r. Housing Supports |
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s. Self-help (AA, OA, NA…) |
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t. Other: |
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v. Other: |
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Domain 2: Cognitive Abilities
Following are a few areas where you might offer some initial understanding and knowledge, and therefore assistance to the patient’s discharge planning process.
1. Does the patient have: (circle one for each category)
a. Reading Skills: Basic or Advanced b. Writing Skills: Basic or Advanced c. Math Skills: Basic or Advanced
2. Can the patient: (check all that apply)
a. ( ) Pay attention to time? b. ( ) Understand his/her illness? c.( ) Understand his/her symptoms?
d. ( ) Recognize dangerous situations? e. ( ) Express/verbalize his/her needs? f. ( ) Understand responsibilities?
g. ( ) Comprehend his/her rights? h. ( ) Understand how to take medication?
3.
Is the patient: (check all that
apply)
a. ( ) Able to plan his/her day by him/herself? b. ( ) Able to plan ahead for him/herself a week at a time?
c. ( ) Able to solve
problems on his/her own? d. ( ) Able to solve problems with help?
4. Please share any other information helpful in developing the patient’s discharge plan: _________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Domain 3: Physical Health
1. List any physical problems. Attach additional sheets if necessary.
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Diagnosis |
Prevalent Symptoms |
Medications and side effects |
Level of Supervision Needed (check one) |
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none |
1 x daily |
2-3 x daily |
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A. |
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B. |
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C. |
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D. |
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E. |
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2. Describe how each problem affects the patient’s level of independence; psychiatric stability; and long-term health. Attach additional sheets if necessary.
A. ______________________________________________________________________________