Free Criteria for High Risk of Nursing Home Admission - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20452 (09/2008)

STATE OF WISCONSIN Wisconsin Statutes 46.277(5)(g)2

CRITERIA FOR HIGH RISK OF NURSING HOME ADMISSION
Completion of this form meets the requirements of Wisconsin Statute 46.277(5)(g)2 and must accompany waiver packet. Failure to complete and submit this form will result in the applicant not being eligible for special CIP II diversion funding. Name ­ Applicant County of Residence

Care Manager must certify that the person: (please check all that apply) Meets functional and financial eligibility for CIP II Is at high risk of a long-term nursing home stay, and Fits in one of the two high risk groups below High Risk Groups Person achieves an Intensive Skilled Nursing (ISN) level of care on the LTC FS, OR OR Person has at least one "yes" response in at least three of the categories (A-E) below (check all that apply). A. Activities of Daily Living · Needs help from a person with eating (not including meal prep) · Needs help from a person with toileting · Needs help from a person with transferring · Has incontinence more than weekly · Has fallen more than once in the last month B. Cognition · Has cognitive impairment that poses a risk to health and safety C. Health Related · Has terminal illness · Has had three or more hospital admissions in the last six months · Has had three or more emergency room visits in the last six months · Takes six or more prescription medications D. Living Arrangement and/or Caregiver Support · Has experienced recent loss of primary caregiver · Family/informal supports are fragile or insufficient · Has no informal caregivers · Faces imminent loss of current living arrangement (includes financial and other factors) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No

E. Other-if applicable Yes · Other circumstances exist that contribute to putting this person at imminent risk of nursing home admission. Describe in detail below but do not duplicate items A. ­ D. above.

No

PRINT ­ Care Manager's Name

SIGNATURE ­ Care Manager

Date Signed