PCMH-Kids High Risk Screening Tool(Updated 6/8/17)

PCMH-Kids High Risk Screening Tool(updated 6/8/17)

Child’s First Name: / Last Name:
DOB: / Current Age:
Primary Care Physician:
Other Treating Clinicians:
Primary Health Insurance:
Reason for referral:
Child/Family Risk Factors: / Current need / Comments
2+ Hospital admissions past 12 months / □
2+ ED visits related to chronic condition / □
2+ ED visits for behavioral health past 12 months / □
1+ Behavioral health hospitalization past 12 months / □
2+ missed MD appointments / □
School issues (low performance, absenteeism, behavior) / □
Foster Care / □
Parent/Caregiver MH concern or cognitive delay / □
Domestic Violence / □
Substance Use: □ Parent □ Caregiver □ Child / □
Food uncertainty / □
Housing Issues / □
Other (please specify) / □

Chronic Conditions: (Please check all that apply)

□ ADD/ADHD / □ Depression / □ Intellectual Disability / □ Seizure Disorder
□ Anxiety / □ Developmental Delay / □ Learning Disability / □ Sickle Cell Anemia
□ Asthma / □ Development screening fail (birth-5) / □ Maternal/Caregiver Depression / □ Speech Problems
□ Autism, Asperger’s, ASD / □ Diabetes / □ MCHAT Fail / □ Suicide Ideation/Attempt
□ Behavioral Problems / □ Down Syndrome / □ ODD / □ Technology Dependence
□ Bone, joint, or muscle problems / □ Eating Disorder / □ Postpartum Depression / □ Tourette Syndrome
□ Brain Injury / □ Epilepsy / □ Prematurity / □ Transition to Adulthood
□ Cerebral Palsy / □ Hearing Problems / □ School Absences (Chronic) / □ Vision Problems
□ Cutting and self-injury / □ Other (please specify):

What outcome would you like to see?:

Other community resources involved in the child’s care:

Does the family require intensive Care Coordination? Was the patient identified on the health plan’s high risk list?

□ Yes□ Yes

□ No□ No

High Risk Qualifiers:

□ at risk for high cost utilization of hospital services;

□ at risk of negative health outcome due to health condition (e.g. clinical risk groups) (Short term (1 year))

□ at risk of negative health outcomes due to social and behavioral and family issues (Longer term (2-5 years))

______

Staff Member Name and Date