Phc Care Transitions Program Patient Screening Form

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PHC Care Transitions Program
Patient Screening Form
Name of Patient: _______________________________ DOB: _____________ Age:_______
Hospital of index admission:__________________________
Date of Admission: __________
Admission diagnosis:_______________________________
Date of Discharge: __________
Primary Care Provider:__________________________ Date of screening evaluation: ___________
Requirements (all of the following must be true):
____ Adult age 18 or over
____ Patient currently eligible for PHC coverage
____ Patient with Medi-Cal only, no Medicare AND not capitated to a hospital (includes “special
member” status).
____ Not enrolled in home visiting NP program or IOPCM.
____ Not being discharged to Hospice, or an intensive pre-hospice palliative care program (for example:
Sutter’s AIM program)
____ Expected discharge disposition within the service area of the Care Transition program.
Four Scoring domains:
Section A can be completed with basic admission information, and may be conducted by a Utilization
Management Nurse.
Section B requires access to the Admission History and Physical (although some areas may be more
complete on conversation with patient)
Section C is available in an Electronic Medical Record. If no EMR is available, this may require patient
interview.
Section D generally requires patient interview or review of social worker/discharge planner notes.
Minimum score needed to enroll in program: 8+ points in Section A, or 20+ points in sections A
through D.
A. Basic Hospitalization Data:
a. Age
i. Age 80+
_____ 3 points
ii. Age 65-79
_____ 2 points
iii. Age 50-64
_____ 1 point
b. Acute Medical Conditions on index admission
i. CHF exacerbation
_____ 5 points
ii. Sepsis
_____ 3 points
iii. Acute MI/unstable angina
_____ 2 points
iv. Pneumonia, GI bleed, COPD exacerbation
_____ 2 points
c. Length of stay on this admission (so far)
i. 5-7 days
_____ 1 point
ii. 8-14 days
_____ 2 points
iii. 15+ days
_____ 3 points
Subtotal A: _______

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