Imminent Risk Survey

Please Complete and Return to DOEA by June 30, 2006

This survey may be completed electronically and sent to OR faxed to 850-414-2313, attention Mindy Sollisch.

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This survey addresses the tracking of imminent risk referrals. We would appreciate your input on this very important issue. Please take a few minutes to answer this seven-question survey. Thank you!

PSA ______Your Name ______Your Title ______

Question 1: During the previous 12 months were you unable to serve individuals referred by CARES who were identified as imminent risk due to reasons out of your control?

Yes ______No: ______

If you answered No above, please skip to Question 3.

Some possible barriers preventing the provision of services to imminent risk referrals are listed below. Please denote how frequently each barrier occurred:

Individual Deceased

Individual Refused Services

Individual Can’t Be Located

Individual Placed in ALF*

Individual Placed with Family**

Individual Placed in NH

Individual Placed in Hospital

No ALF Beds Available in PSA

No Suitable ALF Available

No Funds Available

Will Remain in NH; Most Suitable

* without ALE Waiver services

** family is either out of state or is satisfying the individual’s needs

Question 2: Are there additional barriers preventing the provision of services to imminent risk referrals that you have experienced that are not listed above?

Yes ______No: ______

Describe barriers:

Question 3: Do you have a sufficient number of suitable ALFs in your area to serve imminent risk referrals needing ALF placement?

Yes ______No: ______

If No, what actions, if any, have been taken to improve the number of suitable ALFs?

Question 4: Do you or your lead agencies set aside funds to serve imminent risk referrals? If Yes, explain how the amount is determined. If No, explain why.

Yes ______No: ______

Question 5: In your opinion, is case management alone sometimes sufficient to keep individuals identified as imminent risk in the community (or bring them home out of a nursing home)? Please explain.

Yes ______No: ______

Question 6: In your opinion, what is a reasonable amount of time in which an individual identified as imminent risk should be served from the date of referral? Please explain.

Question 7: Do you have any suggestions as to how we can improve the tracking or serving of individuals identified as imminent risk?

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