SNBC
Institutional Care Coordination Document (ICCD)
*Fields with asterisks are required for MMIS entry
*Client Last Name:
/*Client First Name:
/*M.I.:
Click here to enter text. / Click here to enter text. / Click here to enter text.*Birth Date:
/*PMI Number
/ UCare ID Number:Click here to enter text. / Click here to enter text. / Click here to enter text.
Address:
/ Phone number: /Facility:
Click here to enter text. /Click here to enter text.
/ Click here to enter text.Primary Spoken Language:
/*Referral Date
/ *LTCC CTY:Click here to enter text. /
Click here to enter a date.
/ Click here to enter text.*Activity Type Date (date of assessment)
/*Activity Type
Click here to enter a date.
/Choose an item.
*COS
/*COR
/*CFR
Choose an item. / Choose an item. / Choose an item.*Legal Rep Status – Adult (age 18 or older)
/ Legal Rep Name: / Legal Rep Contact Info:Choose an item. / Click here to enter text. / Click here to enter text.
*Primary Diagnosis Name:
/ Click here to enter text. / *Dx Code: Click here to enter text.*Secondary Diagnosis Name: / Click here to enter text. / *Dx Code: Click here to enter text.
*Is there a history of a DD Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Is there a history of a MI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Is there a history of a BI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Who was present at screening? (more than one can be selected)
☐ 01 – Client ☐ 02 – Family ☐ 03 - LTCC consultant
☐ 04 - Social worker ☐ 05 - Public health nurse ☐ 06 - Hospital discharge
planner
☐ 07 - Qualified mental
retardation
professional
☐ 08 - Qualified mental
health professional / ☐ 09 - NF staff ☐ 10 - Primary physician ☐ 11 - Home care or
community based
service provider
☐ 12 – Advocate ☐ 13 - Conservator/Guardian ☐ 14 - Consulting physician ☐ 15 - ICF/MR staff ☐ 16 - Services for children
with handicaps / ☐ 17 - Case manager ☐ 18 - Legal counsel ☐ 19 - Health plan
coordinator
☐ 20 – Ombudsman ☐ 21 – RRS ☐ 22 - Interpreter, English ☐ 23 - Interpreter, ASL
☐ 98 – Other, please specify: Click here to enter text.
Provider Information
Primary Care Clinic: / Click here to enter text.Primary Care Provider: / Click here to enter text.
Address: / Click here to enter text.
Phone number: / Click here to enter text.
Specialty Provider: / Click here to enter text.
Specialty Provider: / Click here to enter text.
Specialty Provider: / Click here to enter text.
Specialty Provider: / Click here to enter text.
County Financial Worker: / Click here to enter text.
Rule 79 Targeted CM: / Click here to enter text.
*Screening & Assessment Information
*Reasons for Referral:
/*Current Living Situation:
/*Current Housing Type:
Choose an item. / Choose an item. / Choose an item.Dressing
/Grooming
Choose an item. / Choose an item.Bathing
/Eating
Choose an item. / Choose an item.Bed Mobility
/Transferring
Choose an item. / Choose an item.Walking
/Behavior
Choose an item. / Choose an item.Orientation
Choose an item.Self-Preserve
/Communication
Choose an item. / Choose an item.Hearing
/Vision
Choose an item. / Choose an item.Mgt. Meds/Other Treatment
/Insulin Dependent
Choose an item. / Choose an item.Money Management
/Transportation
Choose an item. / Choose an item.Have you experienced any falls in your home or while out in the community?
Choose an item.If yes, what interventions are in place? Click here to enter text.
*Assessment Results and Exit Reasons
/*Effective Date
Choose an item. / Click here to enter a date.*Program Type
/*CDCS
/*Is member on a waiver? ☐ Yes ☐ No
28- SNBC / ☐ Yes ☐ No / Type: Click here to enter text.Waiver CM’s contact info: Click here to enter text.
*Number of Hospitalizations in last year: Click here to enter text.
Please describe: Click here to enter text.
*Number of ER Visits in last year: Click here to enter text.
Please describe: Click here to enter text.
*Number of NF Stays in last 3 years: Click here to enter text.
Please describe: Click here to enter text.
Member Chart Review Section
☐ Reviewed Minimum Data Set (MDS) or other comprehensive health assessment:Date of last MDS: Click here to enter text.
☐ Reviewed cognitive status: Click here to enter text.
☐ Reviewed mood status: Click here to enter text.
☐ Current rehab therapies/skilled services (OT, PT, ST): Click here to enter text.
Notes:
Click here to enter text.
Preventative Care
Review of most recent MD or NP nursing home visit and/or annual PCP visit. Date of visit:Notes:
preventative health measures discussed at visit
Diagnosis:
Medications:
Immunizations: Flu Pneumonia Shingles Tdap Other Type:
Ancillary Care Providers seen in the last year as appropriate:
Podiatry Dental Vision Audiology Psychiatry Other
Notes:
Comprehensive Plan of Care Reviewed:
Multi-Disciplinary Holistic Preventive in Focus Member/Family
Participation
Psychosocial Behavioral Environmental Nutritional Concerns - Wt
loss or gain
Pain Management Skin Integrity Utilizes Facility Services Member/Family
Reviewed Care Plan Goals Reviewed barriers to goals (if any) ADL’s/IADL’s
Notes:
Level of Care Appropriate? Yes No
If no, alternative services Home and Community Based Services (HCBS) addressed.
Is the member able to or wish to move back to the community? Yes No
Notes:
Nursing home plan of care attached in members file: Yes No
Date:
Met with member, reviewed Care Coordinator Role, addressed member concerns (if any)Date:
Notes:
Met family or authorized representative Date:
Notes:
Discussed TOC Date:
Notes:
Members of the ICT
Discussion with Facility Staff
Name: Discipline:Date:
Name: Discipline: Date:
Advanced Directives
Do you have any of the following in place? (Check all that apply)☐ Advanced Directives ☐ Living Will ☐ Durable Power of Attorney for Health Care
☐ Durable Power of Attorney for Financial
~Advance Directive discussion with member completed? ☐ Yes ☐ No
· If no, explain why not? Click here to enter text.
Additional Comments: Click here to enter text.
Assessor Signature: Date: Click here to enter a date.
Assessor Name and Credentials: Click here to enter text.
*NPI/UMPI #: Click here to enter text.
CLS 11/17