Free ForwardHealth Mental Health Day Treatment Functional Assessment, F11090 - Wisconsin


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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11090 (10/08)

STATE OF WISCONSIN HFS 107.13(4), Wis. Admin. Code

FORWARDHEALTH

MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT
INSTRUCTIONS: Type or print clearly. Before completing this form, read the Mental Health Day Treatment Functional Assessment Completion Instructions, F-11090A. SECTION I -- DEMOGRAPHIC AND MEMBER INFORMATION 1. Name -- Member (Last, First, Middle Initial) 3. Date of Initial Assessment

2. 4.

Member Identification Number Date of Reassessment

5. 6.

Member has received _________ hours of day treatment since the initial assessment. Referral Source Hospital Family

Friend Agency

Self Nursing Home

Physician Other _________________________________

7. 8. 9.

Name / Agency -- Referral Source Address -- Referral Source (Street, City, State, ZIP Code) Member presently hospitalized? Member presently living in nursing home? Yes Yes No No 11. Resident of Facility Since Discharge Date _

10. Name / Address -- Facility (Street, City, State, ZIP Code)

12. Usual Living Arrangement Alone. Household with spouse and other relatives or with other relatives only. Group quarters, other than a health-related facility. 13. Reason for Referral

Household with spouse only. Household with nonrelatives. Community-Based Residential Facility (CBRF). Other (Specify) ___________________________________

14. Eligibility Decision Criteria a. b. c. d. e. f. g. Substance abuse currently Yes No Mental retardation primary diagnosis Yes No ICD-9-CM: Primary diagnosis code _____________ Secondary and other code _____________ Scores, level of functioning (LOF) ____ ____ ____ (Sections II-IV), total _____________ Likelihood of benefit (Section V) ____________% Course of functioning (Section V) _____________ Risk of hospitalization (Section V) ____________%

15. Current Services Being Received (Medical and Nonmedical)

16. SIGNATURE -- Assessor 19. SIGNATURE -- Day Treatment Program Director

17. Discipline

18. Date Signed 20. Date Signed Continued

MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT F-11090 (10/08)

Page 2 of 5

Name -- Member

Date of Initial Assessment

Date of Reassessment

SECTION II -- LEVEL OF FUNCTIONING TASK ORIENTATION SCALE Note: You must know firsthand or have it reliably documented that the member has actually done the tasks. Indicators: a. Degree of self-application (concentration, follow through, assuming responsibility) and, if necessary, the amount of guidance (instruction in performance) and support (reinforcement, reassurance) needed to maintain functioning. b. Relationship of level of stress to task functioning and the amount of support needed to engage or re-engage in tasks.
COMMENTS

1.

a. Cannot apply self to any task for any period of time. Demonstrates no goal directed behavior. May wander aimlessly. Guidance and support have no effect on task functioning. b. Cannot cope with any stress.

2.

a. Rarely concentrates. When alone, rarely follows through with tasks. In a highly structured situation with others, very limited task follow-through even with constant guidance and support. b. Functioning breaks down with slightest stress. Needs much support to re-engage.

3.

a. Concentrates intermittently. When alone, limited follow-through. Some follow-through with continuous support; no guidance necessary. b. With low stress, task functioning breaks down. Support needed to re-engage.

4.

a. Concentrates fairly consistently. At times able to follow through. Occasionally assumes responsibility for tasks, when requested to do so, if support is provided. b. With low stress, task functioning is usually diminished. Support needed to re-engage.

5.

a. Follows through frequently and voluntarily assumes responsibility for tasks. Occasionally needs support. b. With low stress, functioning will occasionally be impaired. With moderate stress, functioning will almost always be impaired. Usually needs support to re-engage.

6.

a. Concentration is consistent and purposeful. Follows through well and often assumes responsibility for tasks, only requiring support when under stress. b. With moderate stress, functioning is usually impaired. Can re-engage by self.

7.

a. Concentration is almost always consistent and purposeful. Follows through very well and is actively responsible in relation to tasks. Usually follows through even with frustrating tasks. Task mastery is experienced as valuable and satisfying. Very seldom needs support. b. With moderate stress, can maintain functioning. With high stress, functioning is impaired but can re-engage by self.

8.

a. Excellent concentration and achievement orientation. Very seldom subject to distraction. Follows through even with the most frustrating tasks. Almost never needs support. b. With high stress, functioning only slightly impaired. Can re-engage by self.
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John Williams, M.A., Framingham Day Hospital, Framingham, Massachusetts, with consultation from Iris Carroll, O.T.R., M.P.H., Framingham Day Hospital and Fred Altaffer, Ph.D., Massachusetts Department of Mental Health, August, 1979. Reproduced by ForwardHealth with permission from Programs for People, Inc., 2/14/05. Copyright applied for; reproduction by a process without permission violates copyright laws.

Continued

MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT F-11090 (10/08)

Page 3 of 5

Name -- Member

Date of Initial Assessment

Date of Reassessment

SECTION III -- LEVEL OF FUNCTIONING SOCIAL FUNCTIONING SCALE Note: Social interaction can be in or out of the program. You must know of its occurrence first hand or it must be reliably documented. Social interaction with staff is not to be taken into consideration when rating. Indicators: a. Ability to initiate interpersonal contact. b. Degree of conversational interaction. c. Degree of comfort in interpersonal situations. d. Relationship between level of stress and social functioning. Amount of support needed to engage or re-engage. 1. a. b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. Does not initiate contact. When approached, no response. Shows no ability to listen or respond in conversation. Extreme discomfort being with others. Unable to cope with any stress. Very rarely initiates contact. When approached, sometimes responds. Rarely listens. Responses not appropriate to conversation flow (lack of continuity, coherence). General discomfort with others most of the time. With the slightest stress functioning breaks down. Needs support to re-engage. Rarely initiates contact. If approached, almost always responds. Sometimes listens. Responses occasionally appropriate to conversation flow. Discomfort with others but can tolerate limited supported interaction. With low stress, functioning almost always breaks down. Needs support to re-engage. Sometimes initiates contact. Always responds. Usually listens. Responses often appropriate with some sharing in the conversation flow. Some discomfort but with support can tolerate most interactions. With low stress, functioning at this level usually diminishes. Needs support to re-engage. Often initiates contact. Can listen well. Usually responds in shared way to the conversation flow. Usually comfortable with others in interactions that are not stressful. Under low stress, functioning occasionally breaks down. With moderate stress functioning will almost always be impaired. Usually needs support to re-engage. In most cases can initiate contact. Listens very well. Responds in shared way to conversation flow. At times actively shapes conversation. Usually comfortable in most interactions. With moderate stress, functioning is occasionally impaired. Can re-engage by self. Almost always able to initiate contact as desired. Listens with empathy. Not only responds, but actively shapes conversation appropriately. Not only feels comfortable, but experiences interactions as satisfying. With moderate stress, can maintain functioning. With high stress, functioning diminishes. Can re-engage by self. Initiates contacts as desired. Listens intuitively. Responds and shapes conversations appropriately, as desired. Not only feels comfortable, but experiences being with others as self-enhancing. With high stress, involvement may be diminished, but member is not immobilized.
SCORE THIS PAGE COMMENTS

2.

3.

4.

5.

6.

7.

8.

Framingham Functional Assessment Scale, J. Williams, I. Carroll and F. Altaffer, August 1979. Copyright applied for, Framingham Day Hospital. Reproduction by any process without permission violates copyright laws. Reproduced by ForwardHealth with permission from Programs for People, Inc., 2/14/05.

Continued

MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT F-11090 (10/08)

Page 4 of 5

Name -- Member

Date of Initial Assessment

Date of Reassessment

SECTION IV -- LEVEL OF FUNCTIONING EMOTIONAL FUNCTIONING SCALE Indicators: a. Member's ability to be aware of and understand his emotional states. b. Member's relationship to his emotional states (overwhelmed? sufficiently controlled? a sense of objectivity?). c. Amount of support needed to function emotionally, with varying levels of stress. 1. a. Emotional states appear to be either extremely controlled and rigid (flat) or extremely uncontrolled (labile). Cannot objectively acknowledge his emotions. b. Appears severely overwhelmed by emotional experience. c. Intervention or support has no effect. Emotional states prevent almost all everyday functioning. a. Although may refer to emotional states, reveals no experienced awareness or objective understanding of emotions at the time they occur. b. Excessively overwhelmed by emotions. c. Even with constant support, becomes overwhelmed with slightest stress. Needs support to regain functioning.

COMMENTS

2.

3.

a. Indicates beginning awareness of emotional states, but anxious about this awareness. b. Emerging objectivity in relation to emotions, though frequently overwhelmed by his emotions. c. Even with constant support, in low stress situations, functioning breaks down.

4.

a. Usually aware of emotional states. Indicates an acceptance of emotions as a necessary part of life. May begin to take new actions based on awareness of his emotions. b. Some objectivity in relation to his emotions but often feels overwhelmed by them. c. Even with frequent support, in low stress situations, functioning is diminished. Needs support to regain functioning.

5.

a. Indicates that he is almost always aware of his emotions and is developing an understanding of them. b. Somewhat uncomfortable and overwhelmed by his emotions, but still objective enough to begin to understand them. c. Even with support, emotional functioning is impaired with moderate stress. Needs support to regain functioning.

6.

a. Understands his emotions and how they relate to everyday functioning. Begins to feel comfortable with various emotional states. b. Behavior indicates sufficient emotional objectivity to function with flexibility. c. Emotional functioning somewhat impaired with moderate stress. At times needs some support to regain functioning. a. Not only understands emotions and how they relate to everyday functioning, but experiences this as satisfying, and a part of emotional growth. b. In experiencing diverse emotional states, even extremes, person usually maintains a tempering objectivity. c. With high stress, functioning will diminish. Occasionally needs support to regain functioning. a. Indicates thorough understanding of his emotional life and experiences emotional growth as part of a lifelong process. b. Wide variety of emotions are experienced in a larger context of emotional growth. c. With high stress, functioning slightly impaired. No need for support to regain functioning.

7.

8.

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Framingham Functional Assessment Scale, J. Williams, I. Carroll and F. Altaffer, August 1979. Copyright applied for, Framingham Day Hospital. Reproduction by any process without permission violates copyright laws. Reproduced by ForwardHealth with permission from Programs for People, Inc., 2/14/05.

TOTAL LOF SCORE

Continued

MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT F-11090 (10/08)

Page 5 of 5

Name -- Member

Date of Initial Assessment

Date of Reassessment

SECTION V -- SCORING Likelihood of Benefit from Mental Health Day Treatment. In comparison with other individuals' day treatment preadmission functioning and subsequent success in achieving treatment goals, what is the probable benefit of mental health day treatment to this individual? (Circle Level) Score
0% 10 20 25 30 40 50 60 70 75 80 90 100%

No likelihood of achieving treatment goals

Moderate likelihood in achieving treatment goals

Complete likelihood in achieving treatment goals

Course of Functioning During the Past Year (Circle Level) 1. Vulnerability to stress. What is the likelihood that the individual exhibited severe psychopathological symptoms in response to mild to moderate levels of stress? 1 2 3 4 5 Score

100% 75% Complete likelihood of severe psychopathological symptoms

50% Moderate likelihood of severe psychopathological symptoms

25%

0% No likelihood of severe psychopathological symptoms

2.

1

Activities of daily living skills. What has been the individual's level of functioning with regard to activities of daily living (e.g., bathing, grooming, and dressing; basic housekeeping and shopping; use of public transportation; preparing or obtaining meals; maintaining prescribed program of medication; taking initiative to seek assistance with problems)? 2 3 4 5 Score

Unable to perform three or more essential activities of daily living without assistance

Unable to perform two essential activities of daily living without assistance

Unable to perform one essential activity of daily living without assistance

Marginal performance of activities of daily living

Adequate performance of activities of daily living

Specify: 3.
1

Dependence on institutional and other support systems. To what extent has the individual required mental hospitalizations or other institutional support or been unable to achieve self-sufficient living?
2 3 4 5

Score

Has had mental hospital admission

Has been involved in mental health day treatment

Has not required mental health day treatment or more restrictive care

4.
1

Working in the competitive job market. To what extreme has the individual been unemployed, sporadically employed, or experienced emotionally related job difficulties? 2 3 4 5 Score

Extensive periods of unemployment or serious emotionally-related job difficulties

Moderate difficulty in obtaining or maintaining employment or moderate emotionally related job difficulty

No significant difficulty with regard to competitive employment

5.
1

Interpersonal relations. To what extent has the individual exhibited social withdrawal and/or inappropriate behavior that interfered with interpersonal relationships necessary for community living? 2 3 4 5 Score TOTAL (1-5)

Serious degree of withdrawal and/or inappropriate behavior

Moderate degree of withdrawal and/or inappropriate behavior

No evidence of social withdrawal or inappropriate behavior

0

Risk of Hospitalization. If the individual does not receive mental health day treatment at this time, what is the likelihood of the person requiring inpatient care within the next three months? Note: If feasible, this estimate should be made in comparison with other members with similar diagnoses, levels of functioning, and course of functioning. Also averaging more than one clinical judgment tends to increase the accuracy of this estimate. (Circle Level) Score
0% 10 20 25 30 40 50 60 70 75 80 90 100%

No likelihood of inpatient care

Complete likelihood of requiring inpatient care

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