Community Health Team Referral and Triage Tool

Date of Referral: Practice: (select one): Nurse Care Manager:

Primary Care Provider: Next Office Visit: Pharmacy:

Patient First Name: Last Name: DOB:

Health Insurance: (select one):	Health Insurance Member ID:

Secondary Health Insurance: (select one):	Secondary Insurance ID:

Best Phone Number to Reach Patient: Home/Cell :

Address: City: State: Zip:

Emergency Contact & Support Person (please list name, phone and relationship):

Enrolled in Current Care?	Interpreter Needed?

Is patient aware of referral to CHT? Desired Outcome:

PLEASE INCLUDE MEDICAL SUMMARY

Higher Risk Drivers (3 Points Each)

Utilization (medical or psych): (15 Points Max) IP admit in past 30 days OR 30-day Readmission in past year OR 2+ IP admits in past 6 months OR 2+ ED visits in past 6 months Health Plan High Risk Report – impactable costs actual or predictive > $25,000
High Risk of: (6 Points Max) IP admit/ ED visits in next 6 months Significant decline in functional status/ need for LTC in next 6 months Do you think it likely that pt will pass away in next 12 months or Palliative Care Referral Made?– (Levine Score or Palliative Care Screening Tool ≥ 4)

Moderate Risk Drivers

Poorly Controlled High Risk Chronic Disease (2 Points Total) CAD CHF Diabetes COPD Chronic Pain End stage disease:
RX Meds: 8+ active prescriptions OR recent change in high risk meds (2 Points Total)
Disengagement: significant, chronic condition(s) and (2 Points Total) inadequate follow-up with PCP, or not following care plan, or specialty care without coordination
Disability: significant Physical/ Mental/ Learning disability impacting reasons for referral (2 Points Total)
Psycho-Social risk factors which prevent adequate mgmt of high risk diseases (2 Points Each/ 6 pts max) language/literacy safety homeless poor supports food insecurity undocumented legal status other
Substance Abuse: Actively using, newly sober, motivated to change (2 Points Total) Alcohol Opioid Benzodiazepine Other
Mental Health DX that is severe, persistent, and uncontrolled: (2 Points Total) Schizophrenia Major Depression Bipolar Debilitating Anxiety Other

Fundamental Risk Drivers (1 Points Each)

Chronic Disease/ Co-morbidities – not well controlled/ not noted above (1 Point)
Functional Impairments – Fall risk, impaired ADLs, impaired ambulation, impaired judgment, difficulty getting to appts, unable to follow med regimen (1 Point Each)

>15 = High Risk – Offer Complex CM

<15 = Does not meet criteria of Complex CM

Disposition Plan:

© Cambridge Public Health Commission 2014.