LEVEL 4 LEVEL 3 LEVEL 2 LEVEL 1 Areas of Functioning (4 points) (3 points) (2 points) (1 point) ENVIRONMENTAL (continued) Client has no income and Client has difficulty Client’s income may Client has a steady, stable cannot currently meet maintaining sufficient occasionally be source of income and is FINANCIAL basic needs; income from available inadequate to meeting able to meet monthly OR sources to meet basic needs. financial obligations. Client needs immediate needs; emergency intervention OR to address financial crisis. Client requires frequent ongoing referrals from MCM to stabilize income. Score: Client is experiencing a Client wants assistance Client wants assistance Client has no recent or LEGAL ISSUES crisis involving completing applicable completing applicable current legal problems; matters; advanced directives (living advanced directives (living OR OR will, last will, power of will, last will, power of Client does not want Client is incarcerated or attorney, advanced attorney) and no current assistance with or has recently released from directives) including legal problem. completed all applicable correctional facility; permanency planning; and advanced directives (living OR client has recent or will, last will, power of Client has a current or current minor legal attorney, advanced extensive criminal history; problems; directives). OR OR Client is in need of Client has services to access health issues. Score: benefits. Client Name: Final score: Acuity Level of need assigned: Medical case manager’s signature: ________________________ ______________ ___ Date:
Areas of Functioning LEVEL 4 (4 points) LEVEL 3 (3 points) LEVEL 2 (2 points) LEVEL 1 (1 point) ENVIRONMENTAL (continued) FINANCIAL Score: Client has no income and cannot currently meet basic needs; OR Client needs immediate emergency intervention to address financial crisis. Client has difficulty maintaining sufficient income from available sources to meet basic needs; OR Client requires frequent ongoing referrals from MCM to stabilize income. Client’s income may occasionally be inadequate to meeting needs. Client has a steady, stable source of income and is able to meet monthly financial obligations. LEGAL ISSUES Score: Client is experiencing a crisis involving matters; OR Client is incarcerated or recently released from correctional facility; OR Client has a current or extensive criminal history; OR Client is in need of services to access health benefits. Client wants assistance completing applicable advanced directives (living will, last will, power of attorney, advanced directives) including permanency planning; and client has recent or current minor legal problems; OR Client has issues. Client wants assistance completing applicable advanced directives (living will, last will, power of attorney) and no current legal problem. Client has no recent or current legal problems; OR Client does not want assistance with or has completed all applicable advanced directives (living will, last will, power of attorney, advanced directives). Client Name: Final score: Acuity Level of need assigned: Medical case manager’s signature: ________________________ ______________ ___ Date:
ELECTRONIC_Standardized_Michigan_HIV_MCM_Acuity_Pilot_Tool_2.2016_517969_7.docx