LEVEL 4 3 LEVEL 2 LEVEL 1 of Functioning (4 points) (3 points) (2 points) (1 point) Describes the Client’s primary, self-identified familial relationships particularly any individuals dependent on the Client for life needs; the level of support needed to assist the Client in sustaining these primary relationships; CHILDREN/FAMILIES and the degree to which these relationships impact the Client’s ability to adhere to medical practices. Client is in advanced Client needs ongoing Client needs assistance in Client has no children stage of disease and child are or transition care getting access to living with them; CHILDREN cannot provide care and may also need permanency planning; OR and/or is faced with assistance with Client needs no OR possibility of losing permanency planning assistance. Client needs assistance to children. or parenting classes; disclosure HIV status to OR children; Client has a child with OR special needs. Client needs assistance with respite care/support; parenting classes Client has dependent(s) Client has 3 or more Client has 1-2 dependents Client has no dependents living with them; dependents living with living with them; living with him/her; DEPENDENTS AND them; AND OR Client is experiencing a AND Client needs minimal or Client needs no current crisis related to Without MCM assistance occasional assistance with assistance with dependents. the Client may be at-risk dependents. dependents. of crisis. Score:
of Functioning LEVEL 4 (4 points) 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) CHILDREN/FAMILIES Describes the Client’s primary, self-identified familial relationships particularly any individuals dependent on the Client for life needs; the level of support needed to assist the Client in sustaining these primary relationships; and the degree to which these relationships impact the Client’s ability to adhere to medical practices. CHILDREN Client is in advanced stage of disease and cannot provide care and/or is faced with possibility of losing children. Client needs ongoing child are or transition care and may also need assistance with permanency planning or parenting classes; OR Client has a child with special needs. Client needs assistance in getting access to permanency planning; OR Client needs assistance to disclosure HIV status to children; OR Client needs assistance with respite care/support; parenting classes Client has no children living with them; OR Client needs no assistance. DEPENDENTS Score: Client has dependent(s) living with them; AND Client is experiencing a current crisis related to dependents. Client has 3 or more dependents living with them; AND Without MCM assistance the Client may be at-risk of crisis. Client has 1-2 dependents living with them; AND Client needs minimal or occasional assistance with dependents. Client has no dependents living with him/her; OR Client needs no assistance with dependents.
ELECTRONIC_Standardized_Michigan_HIV_MCM_Acuity_Pilot_Tool_2.2016_517969_7.docx