Has limited or no access to Has PT-1 or agency transport transportation which impacts vouchers/passes but requires Relies on PT-1 or agency supported Has consistent and reliable access to Current Transportation engagement in medical care, MCM assistance to complete transportation vouchers or transportation with no need for Status appointments, and other support applications and/or maintain family/friend agency support services eligibility Has limited language or cognitive Occasionally needs assistance functioning that limits ability to Acuity Score: with transportation to stay coordinate transportation engaged in medical care Comments (include referrals needed): Intensive Need Moderate Need Need Self Management Area of Functioning (3) (2) (1) (0) Nutrition Relies on food pantries, soup Relies on food pantries, soup Relies on food pantries, soup All nutritional are met and/or kitchens, and community kitchens, or other community kitchens or community MCM assistance not needed to food resources 1x per month or food resources less than 1x per food resources on a weekly basis access food assistance more month Needs immediate linkage to medical care due to acute Needs linkage to nutritional problems related to low body counseling to help manage Needs information about nutrition, weight, poor appetite, nausea, chronic or non-urgent health and/or food preparation to improve vomiting, or other urgent health issues that impact nutritional or maintain health Current Nutritional Status issues that impact nutritional status status Receives food related benefits assistance completing Needs a referral to obtain food (e.g. SNAP, WIC, etc.) to meet applications to maintain current related benefits (e.g. SNAP, WIC, nutritional for self or food related benefits (e.g. SNAP, etc.) household WIC, etc.) Relies on access to an agency Is ineligible for food related food program in order to obtain benefits (e.g. SNAP, WIC, etc.) adequate food
Current Transportation Status Has limited or no access to transportation which impacts engagement in medical care, appointments, and other support services Has PT-1 or agency transport vouchers/passes but requires MCM assistance to complete applications and/or maintain eligibility Relies on PT-1 or agency supported transportation vouchers or family/friend Has consistent and reliable access to transportation with no need for agency support Acuity Score: Has limited language or cognitive functioning that limits ability to coordinate transportation Occasionally needs assistance with transportation to stay engaged in medical care Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Need (1) Self Management (0) Nutrition Current Nutritional Status Relies on food pantries, soup kitchens or community food resources on a weekly basis Relies on food pantries, soup kitchens, and community food resources 1x per month or more Relies on food pantries, soup kitchens, or other community food resources less than 1x per month All nutritional are met and/or MCM assistance not needed to access food assistance Needs immediate linkage to medical care due to acute problems related to low body weight, poor appetite, nausea, vomiting, or other urgent health issues that impact nutritional status Needs linkage to nutritional counseling to help manage chronic or non-urgent health issues that impact nutritional status Needs information about nutrition, and/or food preparation to improve or maintain health Needs a referral to obtain food related benefits (e.g. SNAP, WIC, etc.) Receives food related benefits (e.g. SNAP, WIC, etc.) to meet nutritional for self or household assistance completing applications to maintain current food related benefits (e.g. SNAP, WIC, etc.) Is ineligible for food related benefits (e.g. SNAP, WIC, etc.) Relies on access to an agency food program in order to obtain adequate food
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