Download HSR Screening Eval

Haywood Street Respite Screening Evaluation
Haywood Street Respite is a safe haven for the adults who are experiencing homelessness who need to
recuperate post hospital treatment or post-surgery. Friends receive 24 hour accommodations and three
meals a day. Admission is on referral from participating agency. Friends are served on a first come,
first serve basis when eligibility requirements are met.
*We are a non-medical program, so friends must be self-medicating and ambulatory.
*Carefully evaluate each person for compliance with our guidelines and regulations.
*Although friends are expected to remain within the respite facility, we are not a locked unit.
Directions: Please fill out this form completely and fax to Haywood Street Respite at 828-575-2478 along
with any other pertinent documents. Call respite at 575-2477 ext 102 to confirm that fax was received.
Haywood Street personnel will evaluate the appropriateness of your patient. We will contact you by
phone to confirm approval. Patients should arrive at HSR before 5:00 pm. Patients are accepted
seven days a week (non-holiday). Transportation will be provided by discharging facility or HSR as able.
- While reservations are not possible, we will accept referrals 1-2 days prior to discharge
- Referral Accepted Monday-Friday 9:00am-2:00pm
-Depart Instructions Must Accompany patient to HSR
Patient Name:_____________________________________DOB____/____/________
Date of Hospital Admission________________Anticipated D/C date______________
Anticipated length of stay at HSR per MD__________________
Insurance__________________________________________________________
Primary Care Physician (if applicable)________________________________________
Behavioral Health Provider (if applicable)_____________________________________
Discharge diagnosis_____________________________________________________
Co-Morbidities_______________________________________________________
__________________________________________________________________
Recuperative Care Needs-________________________________________________
Does this patient have a mental illness for which he/she receives treatment?
Has he/she been on behavioral medications for at least 21 days?
Is he/she awake and oriented?
Is his/her behavior appropriate for a group living situation?
Is he/she independent with ADL’s including personal care in restroom?
Is he/she able to manage their medications?
Is he/she willing and able to participate in discharge instructions and follow up care?
Does he/she have discharge instructions?
Does he/she have FU with PCP and/or specialist?
FU-_______________________________Date________________
FU-_______________________________Date________________
Y
Y
Y
Y
Y
Y
Y
Y
Y
Was he/she on ISOLATION during hospital stay?
Is he/she a Smoker?
If YES, are they willing to adhere to the smoking policy at HSR?
Is he/she on probation or have current legal charges?
Has he/she reviewed and agreed to the HSR Covenants and Respectful Living Agreement?
Define relationship with WNCCHS if applicable: ___________________________
Is he/she an active/current patient at WNCCHS?
Date of last appointment-________________
Will he/she be a new patient at WNCCHS?
Date of new patient appointment-_______________
Has enrollment packet been supplied to pt?
Has Yvette Jives and the Transitional Care Team at WNCCHS been contacted?
If he/she is to be a NEW PATIENT at WNCCHS, have medications been supplied for 30 days?
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Y
N
Y
N
Y
Y
Y
N
N
N
For data collection purposes, what alternate discharge plan is being considered for this patient?
Discharged where to?
Expected number of nights spent there:
Skilled facility
Shelter
Motel
Extended hospital stay
Other:
Referring Physician Signature_________________________________________________
Form completed by-_________________________________________________
Phone-_______________________
Fax-_____________________
=====================================================================
APPROVED___NOT APPROVED___REASON_______________________________
Signed________________________________________Date__________________