Clinical Assessment

 

The information gathered in this Clinical Assessment will be used in two ways.  The first is to assist the members of the Community Support Plan team to develop a comprehensive and relevant community support plan for the patient.  The second is to provide information to Counties to coordinate and develop needed community resources for patients discharged from Mayview State Hospital.

The patient’s social worker is responsible for gathering the information to complete this clinical assessment.  All members of the patient’s treatment team, particularly those who know the patient ‘the best’, must participate in completing this assessment so the most comprehensive and up to date clinical information is available for Community Support Plan meetings.  If the patient has identified a staff member who is not an official member of the treatment team but who knows the patient well, that staff member can also be included in completing the assessment. In addition, the social worker must gather information from the assigned County and/or Provider Hospital Liaison.  All parties who contribute to the assessment must sign page 2 of this document.

There are a variety of ways to collect information to complete the Clinical Assessment.  The team can meet as a whole to complete the assessment or individual team members can complete the assessment during ‘downtime’, privately, in an office, or in a common space where the assessment is available twenty-four seven.  The only requirement is that the assessment be completed seven (7) working days prior to the first scheduled Community Support Plan meeting for the patient.

 

First Name: ___________________________ MI: ______ Last Name: ____________________________________

Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Date of birth (month, date, year): ___ ___ / ___ ___ /  ___ ___ ___ ___

County of last residence:   _______________________________________

Unit: _______________                Hospital Liaison: _______________________________________

 

Name of clinician coordinating clinical assessment: _______________________________________

Date of assessment meeting: ___ ___ / ___ ___ /  ___ ___ ___ ___

 

Treatment team members participating in assessment:

 

Name

Signature

Position/Role

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

1.                  Please identify the patient’s insurance coverage.

____Medical Assistance, if yes, provide number _____________________

____Medicare, if yes, provide number _________________________________

____Commercial Insurance, if yes, provide number ______________________

____Veterans Administration, if yes, provide number _____________________

Please identify the patient’s income source and the monthly amount. ________________________________________________________________________________________

________________________________________________________________________________________

What benefits is the patient eligible to receive in the community? ________________________________________________________________________________________

________________________________________________________________________________________

If the consumer currently has a payee, please provide name and contact information.
________________________________________________________________________________________

________________________________________________________________________________________

If the consumer currently has a Power of Attorney, please provide name and contact information.

________________________________________________________________________________________

If the consumer currently has a Legal Guardian, please provide name and contact information.

________________________________________________________________________________________


 

Domain 1: Living

 

1.      First, what town did the patient live in before coming to Mayview? 

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

 

2.      Right before coming to Mayview, what type of place did the patient live in and whom did he/she live with?

(Do not include acute services when answering this item.)

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

 

3.      a) The next time the patient is discharged, is there a particular neighborhood, town, or city you would recommend he/she live in?  _______________________________________________________________________________________

 

_________________________________________________________________________________________________

 

 

b) Why?  ____________________________________________________________________________________________

 

__________________________________________________________________________________________________

 


 

 

4.      List residential type and level of support for the five (5) years prior to admission. Please include treatment services, case management services, housing and vocational supports, natural supports, etc. in the Community Supports column. Attach additional sheets if necessary.

 

Start Date

End Date

Residential Type

Who Living With

Community Supports

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.      Check whether you would recommend the living arrangement below for the patient and how much professional support you recommend he/she would need in the setting. Please note that ‘outpatient help’ refers to Case Management, Community Treatment Team, Psychiatry, and Rehabilitation.  Answering the frequency of how much help is needed will help the team in the planning process to understand the general level of needed community supports.

 

 

Housing Choices

 

Very much

 

A Little

 

Not At All

a. Live in a house, apartment, or room by self

 

 

 

b. With: 

( )Daily Outpatient Help  (  )  Weekly Outpatient Help    (  )  Monthly Outpatient Help    (  ) No Outpatient Help

 

6.      Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.

 

 

Housing Choices

 

Very much

 

A Little

 

Not At All

a. Live in a house, apartment, room w/ family 

 

 

 

b. With:  

(  )  Daily Outpatient Help  (  )  Weekly Outpatient Help    (  )  Monthly Outpatient Help    (  ) No Outpatient Help

 

 

7.      Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.

 

 

Housing Choices

 

Very much

 

A Little

 

Not At All

a.  Live in a house, apartment, room w/roommate(s)

 

 

 

 

 

b. With:  

(  )  Daily Outpatient Help  (  )  Weekly Outpatient Help    (  )  Monthly Outpatient Help    (  ) No Outpatient Help

 


 

8.      Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.

 

 

Housing Choices

 

Very much

 

A Little

 

Not At All

a.  Live in a transitional rehabilitation group setting with other clients and 24/7 staff support on-site w/roommate(s)

 

 

 

 

b. With:  

(  )  Daily Outpatient Help  (  )  Weekly Outpatient Help    (  )  Monthly Outpatient Help    (  ) No Outpatient Help

c. How long do you think he/she needs to live here? 

 

9.      Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.

 

 

Housing Choices

 

Very much

 

A Little

 

Not At All

a.  Live in a permanent group setting w/other clients and 24/7 staff support on-site room w/roommate(s)

 

 

 

 

b. With:  

(  )  Daily Outpatient Help  (  )  Weekly Outpatient Help    (  )  Monthly Outpatient Help    (  ) No Outpatient Help

 

10. Check whether you would recommend this living arrangement for the patient and how much professional support you recommend he/she would need in the setting.

 

 

Housing Choices

 

Very much

 

A Little

 

Not At All

a.  Other (Describe)

 

 

 

 

b. With:  

(  )  Daily Outpatient Help  (  )  Weekly Outpatient Help    (  )  Monthly Outpatient Help    (  ) No Outpatient Help

 

 

11. If he/she shares a living space, how many people do you recommend he/she lives with in a:

 

a) room                                                           __________   

b) apartment                                                  __________

c) house                                                         ___________

c) supervised setting                                    __________

 

 

12. If he/she shares a living space, what age group do you recommend he/she live with?  ___________________

 

 

13.  Where did he/she do the best when living in the community?

 

_________________________________________________________________________________________

 

 

b. Why?  __________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

14. What does the patient already know that will help him/her live successfully in the community? 

 

_________________________________________________________________________________________________

 

 

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

 

 

 


 

15. This is the last question under housing.  Check whether you recommend he/she would do better being in walking distance of each place or if it wouldn’t matter if he/she has to take a bus to get there.

 

Resources/Amenities

Able to Walk to…

Able to Take a Bus to…

Doesn’t matter…

a.     See Family & Friends

 

 

 

b.    A Bus Stop

 

 

 

c.     Open spaces/Parks

 

 

 

d.    Church, Synagogue, Mosque, etc.

 

 

 

e.    Malls/shopping areas

 

 

 

f.       A Food bank

 

 

 

g.    A Library

 

 

 

h.     A Grocery Store

 

 

 

i.        A Pharmacy

 

 

 

j.        A Post Office

 

 

 

k.     Museums

 

 

 

l.        Sport/fitness centers

 

 

 

m.  Drop-in Centers

 

 

 

n.     Drug/Alcohol Counseling

 

 

 

o.    Medical services

 

 

 

p.    Dentist

 

 

 

q.    Mental Health Clinic

 

 

 

r.       Housing Supports

 

 

 

s.     Self-help (AA, OA, NA…)

 

 

 

t.       Other:

 

 

 

u.     Other:

 

 

 

v.     Other:

 

 

 


Domain 2:  Cognitive Abilities

                       

Following are a few areas where you might offer some initial understanding and knowledge, and therefore assistance to the patient’s discharge planning process. 

 

 

1.      Does the patient have: (circle one for each category)

 

            a. Reading Skills:  Basic or Advanced         b. Writing Skills:  Basic or Advanced         c. Math Skills:  Basic or Advanced

 

2.    Can the patient: (check all that apply)

 

   a. (  ) Pay attention to time?                                  b. (  ) Understand his/her illness?                            c.(  )  Understand his/her                                                                                                                                                                                        symptoms?

                       

   d. (  ) Recognize dangerous situations?  e. (  ) Express/verbalize his/her needs?                 f. (  ) Understand                                                                                                                                                                                                 responsibilities?       

    

    g. (  ) Comprehend his/her rights?                      h. (  ) Understand how to take medication?

 

                                   

3.    Is the patient: (check all that apply)

   a. (  ) Able to plan his/her day by him/herself?                b. (  ) Able to plan ahead for him/herself a week at a time?             

 

   c. (  ) Able to solve problems on his/her own?    d. (  ) Able to solve problems with help?

 

4.    Please share any other information helpful in developing the patient’s discharge plan:  _________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 


 

 

Domain 3:  Physical Health

 

1.                  List any physical problems. Attach additional sheets if necessary.

 

Diagnosis

Prevalent Symptoms

Medications and side effects

Level of Supervision Needed

(check one)

none

1 x daily

2-3 x daily

A.

 

 

 

 

 

B.

 

 

 

 

 

C.

 

 

 

 

 

D.

 

 

 

 

 

E.

 

 

 

 

 

 

 

 

2.                  Describe how each problem affects the patient’s level of independence; psychiatric stability; and long-term health. Attach additional sheets if necessary.

 

A. ______________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

B. ______________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

C. ______________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

D. ______________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

E. ______________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________


Domain 4:              Psychiatric Health

 

  1. Complete Table. Attach additional sheets if necessary.

Diagnoses

Medications

Specific to patient,

List Observable

Side Effects of Medications

Axis I

 

 

Axis II

 

 

Axis IV

 

 

Axis V

 

 

 

 

  1. Describe the persistent symptoms the patient experiences at baseline?

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

  1. Do the patient’s psychiatric symptoms emerge steadily and predictably or suddenly and unpredictably? Describe.

 _________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

  1. What are the patient’s triggers to using drugs or alcohol?

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

  1. Please list any high-risk behaviors, thoughts, feelings, and symptoms the patient has experienced in the past 5 years.

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

  1. What interventions do you recommend during increased behavioral, negative and/or positive psychiatric symptoms?

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

  1. Describe the progress the patient has made since admission.

 

_________________________________________________________________________________________________

 

_________________________________________________________________________________________________

 

Domain 5:  Education and Work

 

1.                  What has the patient shared about his/her plans for the future prior to his/her first experience with mental illness?

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

 

2.                 a. Before coming to Mayview, did the patient ever have a paying job whether ‘under the table’ or not?

 

                        Yes                                             No                                               Unsure

 

            b. If yes, what kind of job?_______________________________________________________________

 

_______________________________________________________________________________________

 

 

3.                  a. Before coming to Mayview, did the patient ever have a volunteer job?

 

                        Yes                                             No                                               Unsure

 

                  b. If yes, where? ______________________________________________________________________

 

_______________________________________________________________________________________

 

 

4.                  a. Would you recommend the patient work a paying job after discharge?

 

Yes                            No                           Unsure

 

      b. If yes, give at least two examples of what you think the patient would want to do:

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

 

5.                  a. Would you recommend the patient work a volunteer job after discharge?

 

Yes                            No                           Unsure

 

      b. If yes, give at least two examples of what you think the patient would want to do:

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

 

6.                  a. Would you recommend the patient further his/her education or get job training after discharge?

 

Yes                            No                           Unsure

 

b. If yes, give two examples of what you think the patient would want to do:

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 


 

Domain 6:           Social and Relationships

 

In this section, please comment on the patient’s relationships with others both in Mayview and in the community.

 

1.                  Does the patient have any close relationships with other patients at Mayview? ______________________

 

___________________________________________________________________________________________

 

____________________________________________________________________________________________

 

 

2.                  Is there another patient(s) that you might recommend being discharged with the patient to the same residence?

 

___________________________________________________________________________________________

 

___________________________________________________________________________________________

 

3.                  Upon discharge, is there someone in the community you would recommend the patient live near?____________________________________________________________________________________  

 

In the same home? __________________________________________________________________________

 

 

4.                  How often does the patient go off-grounds and with whom?

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 


 

5.                  What does the patient typically do when he/she is off-grounds?

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

6.                  From what you know about the patient, what activities does he/she enjoy the most in the community?

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

 

7.                  Who would you recommend the patient have contact with after discharge? ____________________

 

Explain: ____________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

 


 

Domain 7: Supports

 

  1. Please rate the amount of help you recommend that the patient receive in each area below to make his/her discharge arrangement successful. 

(Check the boxes that apply)

 

Area

1

Need Help Daily

2

Need 

Help Weekly

3

Don’t Need

Help

1.      Cooking

 

 

 

2.      Menu Planning

 

 

 

3.      Using appliances

 

 

 

4.      Cleaning

 

 

 

5.      Shopping

 

 

 

6.      Use of the telephone

 

 

 

7.      Use of keys and locks

 

 

 

8.      Roommate issues

 

 

 

9.      Providing for personal safety

 

 

 

10. Learning about the neighborhood

 

 

 

11. Working with landlord

 

 

 

12. Getting and keeping a job

 

 

 

13. Going back to school/job training

 

 

 

14. Reading

 

 

 

15. Writing

 

 

 

16. Making/following a daily schedule

 

 

 

17. Keeping appointments

 

 

 

18. Getting a driver’s license

 

 

 

19. Taking the bus

 

 

 

 

 

Please rate the amount of help you recommend that the patient receive in each area below to make his/her discharge arrangement successful. 

(Check the boxes that apply)

 

Area

1

Need Help Daily

2

Need 

Help Weekly

3

Don’t Need

Help

20. Making friends

 

 

 

21. Visiting family

 

 

 

22. Finding things to do

 

 

 

23. Meeting neighbors

 

 

 

24. Connecting with religious center

 

 

 

25. Joining a sports team or club

 

 

 

26. Getting medical and dental care

 

 

 

27. Personal hygiene

 

 

 

28. Seek/ask for help when needed

 

 

 

29. Outpatient mental health care (case management, counseling, management of mental illness, etc.)

 

 

 

30. Outpatient drug and alcohol care (counseling, case management, management of relapse, etc.)

 

 

 

31. Learning about dosage, side effects, purpose of meds

 

 

 

32. Getting and taking medication

 

 

 

33. Connecting with self-help groups

 

 

 

34. Getting exercise

 

 

 

35. Safe sexual practices

 

 

 

36. Getting and keeping benefits

 

 

 

37. Paying bills

 

 

 

38. Banking

 

 

 

39. Legal problems

 

 

 

40. Other

 

 

 

41. Other

 

 

 


2.  This set of questions refers to the patient’s family.  Please rate the amount of help per service/support you recommend that the patient’s family receive to make the discharge arrangement successful. 

(Check the boxes that apply)

 

Area

1

Need Help Daily

2

Need 

Help Weekly

3

Don’t Need

Help

1.      Linkage with other families

 

 

 

 

  1. Hotlines or Warm lines

 

 

 

 

  1. Outpatient mental health care (CM, counseling, management of mental illness, etc.)

 

 

 

 

  1. Outpatient drug and alcohol care (counseling, CM, management of relapse, etc.)

 

 

 

 

  1. Learning about dosage, side effects, purpose of meds

 

 

 

 

  1. Family psycho-education

 

 

 

 

  1. Assist in understanding the patient’s medical care needs

 

 

 

 

  1. Understanding SS, SSI, Insurance/other benefits

 

 

 

 

  1. Other:

 

 

 

 

  1. Other:

 

 

 

 

 

 

3. Is there anything else you can recommend that the patient needs to help make his/her discharge a comfortable and successful community living experience?  For example: in-home fixtures for physical accessibility; a first floor room or an elevator, special ambulation devices like hearing and visual supports; special dietary programs; freedom from specific allergens, objects, people, buildings, or anything associated with any fears he/she has such as (animals, power plants, police stations, etc.), and finally, any special linguistic, cultural, ethnic, sexual needs.

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________

 

_______________________________________________________________________________________