Long Island BHM Initial Clinical

Beneficiary Name: Beneficiary Medicaid ID: Provider Name: Provider Medicaid ID:

Beneficiary DOB: Contact Name for Concurrent Review: Contact Phone #:

Admission Date: Admit Time: Type of Service: Mental Health Inpt Substance Abuse Detox Substance Abuse Rehab

DX: Primary Axis 1: Secondary Axis 1: Primary Axis 2: Secondary Axis 2: Primary Axis 3:

Secondary Axis 3: Axis 4 (Check all that apply):

None / Educational Problems / Financial Problems
Housing Problems / Occupational Problems / Problems w access to health care services
Problems related to interaction w legal system/crime / Problems w Primary support group / Problems related to social environment
Other psychosocial & environmental problems / Unknown

Primary Precipitant (Check only one) Axis 5 (current): Is this a first psychotic break? Yes No

Adjustment due to relocation / Change in mental status / Parent-child conflict / Reaction to medication
Financial crisis/job loss / Legal problems / Legal problems / Medication non-compliance
Treatment non-compliance (Other than medications) / Occupational/school performance/behavioral problem / Currently intoxicated/in withdrawal / Physical/sexual/emotional abuse or trauma
Police/emergency detention / Death or serious medical condition of a loved one / Reaction to serious medical condition (self) / Relationship conflict/loss
Unable to care for self / Other** / Unknown

**Details if Other:

For Mental Health admissions –

Was substance abuse a significant factor contributing to this admission? Yes No Unknown

Was this Beneficiary readmitted from a MH facility within 30 days? Yes No Unknown

If so – was the readmission to the same provider? Yes No

For Substance Abuse admissions –

Did a comorbid Mental Health condition play a significant role in contributing to this admission? Yes No Unknown

Was this Beneficiary readmitted from a SA facility within 45 days? Yes No Unknown

If so – was the readmission to the same provider? Yes No

Beneficiary Name: Beneficiary Medicaid ID: Provider Name: Provider Medicaid ID:

For readmissions the readmission was attributable to (check all that apply)

Previous provider did not offer referral / Uncontrolled acute symptoms on discharge
Beneficiary refused referral / Lack of transportation to outpatient level of care
Beneficiary failed to link with next level of care provider / Financial barriers to follow-up care
Disengaged from post-discharge treatment / Poor motivation for treatment
Appropriateness of level of care referred / Distance to outpatient level of care provider
Medication non-adherence / Delay in appointment with outpatient provider
Lack of post-discharge medication / Beneficiary not in agreement with plan
Loss of housing/unstable housing / Physical health issues complicated ability to follow discharge plan
Substance use/abuse / Linkage to PCP not made
Inadequate discharge supports offered / Medication treatment refractory
New external stressors / Previous discharge on 72 hours letter

Where was beneficiary admitted from? (Check only one)

Correctional facility / OPWDD Developmental Center / Homeless- Shelter
Nursing Home or health related facility / Private Psychiatric Hospital / Homeless- Street
SUD Inpatient Rehabilitation / Article 28 Hospital / OASAS/SUD Community Residence
State Psychiatric Center / DOH Adult Home / OPWDD Community Residence
OCFS Institutional Setting for Youth (Residential Treatment Center or OCFS Juvenile Justice Facility) / OCFS/ACS/DSS Community Residential Program (Family Foster Care Group Home, Therapeutic Foster Care) / Mental Health Community Residence (all types)
Children and Youth RTF / Private Home or apartment / Other

Did the beneficiary have a care coordinator prior to admission? Yes No Unknown

If Yes – has the care coordinator been contacted by the hospital during this admission? Yes No Unknown

Is the beneficiary enrolled in a Health Home? Yes No Unknown Name of Health Home: Phone #:

Was the current or prior MH Outpatient provider contacted? Yes No Not applicable Unknown

Was the current or prior SA Outpatient provider contacted? Yes No Not applicable Unknown

Did non-adherence with antipsychotic medication contribute to this admission? Yes No Unknown

If yes, primary reason for non-adherence (Check only one)

Inadequate insurance coverage / Co-morbid substance abuse / Cognitive dysfunction
Inadequate funds (includes lack of funds for medication, transportation to pharmacy, etc.) / Negative perception of treatment (poor treatment alliance, negative attitude about taking medications) / Poor motivation due to illness (includes poor insight, denial of illness, psychosis, hopelessness, depression, etc.)
Poor motivation due to other factors / Complexity of medication regimen / Intolerable side effects
Poor psychosocial support for medication adherence / Other

Beneficiary Name: Beneficiary Medicaid ID: Provider Name: Provider Medicaid ID:

Did non-adherence with other medications contribute to this admission? Yes No Unknown

If yes, primary reason for non-adherence (Check only one)

Is beneficiary medication treatment refractory upon admission (inadequate treatment response despite adherence with medication at therapeutic does)?

Yes No Unknown

Does this beneficiary qualify for AOT? Yes No If Yes, date of application:

Does this beneficiary qualify for SPOA application? Yes No If yes, date of application:

Date of 1st housing interview: Housing availability date:

Was a referral to Case Management made? Yes No Unknown

Date of application: if yes, Response Date:

Was Case Manager assigned? Yes No Unknown If yes, date case manager assigned:

Beneficiary’s ability to adequately understand and follow post-discharge recommendations: Adequate Fair Inadequate

Estimated discharge date:

Beneficiary Name: Beneficiary Medicaid ID: Provider Name: Provider Medicaid ID:

Tentative discharge plan interventions (Check all that apply)

TREATMENT / COMMUNITY BASED RESOURCE / PRIMARY CARE / MEDICAL SERVICES
Referral for Individual/Group/Marital therapy / Referral to MICA residence / Referral to primary care
Referral for family therapy / Consumer Support / Communication with primary care physician
Referral to State Hospital / Drop in Center / Lab work prescribed
Referral to mental health clinic/outpatient / Advocacy Group / Referral to nutritionist
Referral to IPRT / Referral to AA/NA Al-Anon / Referral for medical follow-up
Referral to substance abuse treatment / Psychosocial Club / Transfer for acute medical treatment
Referral to Intensive Outpatient Treatment / Referral to Domestic Violence Coalition / Visiting nursing services appointment
Psych home care / Referral to MRDD residence / Referral to Nursing Facility
Referral to mobile crisis / Sober Housing / Weight management program
Assisted outpatient treatment / Refer to self-help group
Referral to PROS / VOCATIONAL / CASE MANAGEMENT SERVICE
Long term residential treatment / Referral for vocational services / ACT Team Services
Referral to continuing day tx / partial care / Assisted Competitive Employment (ACE) / Blended case management
COORDINATION / Volunteer work / Supportive case management
Communication with case manager / VESID / Intensive case management
Adult protective services notified / MEDICATION MANAGEMENT
Family Psychoeducation / Long acting injectable medication started / Monitoring of metabolic side effects
Parole officer/probation officer/ TASC workers or other legal/mandating agencies / Medication assisted treatment (methadone, Buprenorphine, Suboxone, etc.) / Med adherence monitoring system put in place (family, pill counting, supervised meds)
Referral to school guidance counselor or school counseling services / Long acting injectable antipsychotic initiated/prescribed / More acceptable alternative medication provided to improve adherence
Application for entitlements / Dose regimen modified for increased adherence / Medication regimen adjusted
Child protective services notified / Medication prescribed/provided on discharge

Date Completed: Form completed by:

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