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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__________________