LEVEL 4 LEVEL 3 LEVEL 2 1 Areas of Functioning (4 points) (3 points) (2 points) (1 point) Describes the Client’s current social and physical environment; how contributing environmental factors either ENVIRONMENTAL support or hinder the Client’s ability to maintain medical care and achieve positive health outcomes; and the level of external support needed to address critical barriers to successful outcomes. Client reports that he/she Client reports that he/she Client self-reports a Client self-reports no DOMESTIC VIOLENCE is currently engaged in has experienced domestic history of domestic history of domestic physically, sexually and/or violence, but is not in violence. violence in the past 12 emotionally abusive abusive relationship; months; relationship and feels life OR OR is in danger of violence. Client is removed from MCM observes visible abuser. evidence that the Client may be at risk. Score: Client is homeless, living Client is in transitional or Client currently has Client is in permanent LIVING SITUATION in a shelter, sleeping on unstable housing; adequate housing but housing and is not in streets or in his/her car; OR may need occasional danger of losing housing. OR Client is at-risk of short-term rent or utilities Client is in immediate eviction, having utility(s) assistance to remain danger of becoming shutoff and/or of losing stable. homeless and needs housing due to financial housing placement ; strain; OR OR Client is unable to live Client assistance with independently and rent/utilities to maintain needs to be placed in housing. assisted living facility. Score:
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) 1 (1 point) ENVIRONMENTAL Describes the Client’s current social and physical environment; how contributing environmental factors either support or hinder the Client’s ability to maintain medical care and achieve positive health outcomes; and the level of external support needed to address critical barriers to successful outcomes. DOMESTIC VIOLENCE Score: Client reports that he/she is currently engaged in physically, sexually and/or emotionally abusive relationship and feels life is in danger of violence. Client reports that he/she has experienced domestic violence in the past 12 months; OR MCM observes visible evidence that the Client may be at risk. Client self-reports a history of domestic violence, but is not in abusive relationship; OR Client is removed from abuser. Client self-reports no history of domestic violence. LIVING SITUATION Score: Client is homeless, living in a shelter, sleeping on streets or in his/her car; OR Client is in immediate danger of becoming homeless and needs housing placement ; OR Client is unable to live independently and needs to be placed in assisted living facility. Client is in transitional or unstable housing; OR Client is at-risk of eviction, having utility(s) shutoff and/or of losing housing due to financial strain; OR Client assistance with rent/utilities to maintain housing. Client currently has adequate housing but may need occasional short-term rent or utilities assistance to remain stable. Client is in permanent housing and is not in danger of losing housing.
ELECTRONIC_Standardized_Michigan_HIV_MCM_Acuity_Pilot_Tool_2.2016_517969_7.docx