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Flex Care Services Application Flex Care Services are part of short term treatment setting to assist members in gaining the skills to live independently.

Directions Complete all areas of the application and indicate the amount of Flex Care Services based upon the member’s skill sets and clinical team recommendations. Applications for Flex Care Services are valid for no more than 90 days (does not apply to Step Down/Step Up/Transfers). If the member still needs Flex Care Services after 90 days a new application will need to be submitted. Please submit the completed application to the Mercy Care Housing Department at: flexcare@MercyCareAZ.org

New Application Step Down/ Step Up/Transfer

MEMBER INFORMATION

Name: DOB: Sex: Male Female

Title 19: Yes No AHCCCS# : SSN#:

Member’s preferred language:

ESL Interpreter Sign Language Limited English Proficiency Translation

Diagnosis:

CLINICAL TEAM INFORMATION

PNO: Clinic: Phone:

CM: CM email:

CC: CC email:

CD: CD email:

ACT Supportive

IDENTIFICATION-minimum 1 ID required

Identifications are required for Flex care settings, if the member does not have these documents referrals may be declined:

Does the member have a photo ID?: Yes No Requested Date of Request:

Does the member have a Social Security Card?: Yes No Requested Date of Request:

Does the member have a Birth Certificate?: Yes No Requested Date of Request:

The clinical team has verified that member has all identifications prior to application submission:

Staff person who verified: Date verified:

** Clinical team is responsible to assist member in obtaining any missing identifications as they may be needed for a successful admit to Flex Care

FINANCIAL AND LEGAL

Does the member have monthly income?: Yes No If yes, total amount:

Does the member have a payee?: Yes No If yes, name and contact information:

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☐ Member Legal Information:(check all applicable options)

Probation Parole COE COT Guardian OHR

Is the member in jail?: Yes No Release contingent upon placement?: Yes No

Use to research state of AZ possible criminal history:

http://apps.supremecourt.az.gov/publicaccess/caselookup.aspx?AspxAutoDetectCookieSupport=1

Sex Offender: Yes No Level: Charge:

Felony: Yes No If Yes, what charge(s) and when?:

Misdemeanor: Yes No If yes, list charge(s) and when?:

LIVING ENVIRONMENT

Current living status: Is the member homeless?: Yes No

Inpatient? Yes No Location:

Has the member lived independently? Yes No If yes how long? :

SUBSTANCE USE/ABUSE

History of substance abuse?: Yes No Date of last use:

Length of substance use history: If yes, primary drug of choice:

List Substance Abuse Treatment History

Type of service: Date:

Type of service: Date:

Type of service: Date:

Free from intoxication of withdrawal risk: Yes No How long:

MEDICAL

Any chronic/complicated medical issues that could benefit from additional staff coordination while receiving services? :

Yes No If yes, please explain:

Cognitive impairments?: Yes No If yes, please explain:

Does the member require any special accommodations? (please check all options that apply)

Wheelchair Ramp Fully Wheelchair accessible Grab bars in shower/commode Uses Walker

Ground floor needed Vision Impaired Hearing Impaired Non-verbal Other:

ACTIVITIES OF DAILY LIVING ASSESSMENT

Please answer the below items based on the below scale: 1 = Member is not able to complete/perform the task 2= Member needs regular oversight/prompts to complete/perform the task 3= Member needs some oversight/prompts to complete/perform the task 4 = Member is able to perform the task independently

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HOME MANAGEMENT

Able to keep place of living clean (cleaning, dishes, etc.).

Able to wash clothes (sort clothing, Laundry facilities and money).

HEALTH AND SAFETY

Able to use appropriate emergency services.

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Can understand and is knowledgeable of basic first aid without supervision.

Is aware of their personal safety (doors locked, use caution with strangers). ☐ ☐ ☐ ☐

Able to handle potentially violent and/or threatening situations in an appropriate manner. ☐ ☐ ☐ ☐

Requires 24 hour monitoring due to overnight dangers: Yes ☐ ☐No (if yes, has BHRF been considered?)

Please explain any unsafe overnight behaviors: ______________________________________________________________________________________

PERSONAL HYGIENE MAINTENANCE and HEALTH AWARENSS

Able to select an appropriate wardrobe (weather, socially acceptable, events, activities). ☐ ☐ ☐ ☐

Able to recognize and maintain good hygiene habits. ☐ ☐ ☐ ☐

Uses hygiene products daily for grooming techniques including hair, dental, bathing. ☐ ☐ ☐ ☐

Can contact the pharmacy for prescriptions and manage his/her prescriptions in their home. ☐ ☐ ☐ ☐

Can take medications as prescribed. ☐ ☐ ☐

MEAL PREPARATION

Able to grocery shop on their own (budget, grocery list). ☐ ☐ ☐ ☐

Knows how to store and handle food to avoid sanitation concerns or eating unsafe items. ☐ ☐ ☐ ☐

Able to use a stove, microwave, oven, etc. ☐ ☐ ☐ ☐

COMMUNITY SERVICES, SOCIAL AND TRANSPORTATION

Can recognize and avoid dangerous and abusive relationships and friendships. ☐ ☐ ☐

Currently involved in meaningful community activities Yes No What:

Comments:

SUMMARY:

CHOOSE THE BEST AMOUNT OF OUTPATIENT SUPPORTS AND NOTE IN THE DROP DOWN BOX BELOW FLEX-CARE OR FLEX-CARE-CO (UP TO 12 HOURS OF SERVICES AND SUPPORTS) (SCORES MOSTLY 3 & 4)

FLEX-CARE PLUS OR FLEX-CARE PLUS-CO (12 OR MORE HOURS OF SERVICES AND SUPPORTS) (SCORES MOSTLY 2 & 3)

FLEX-CARE-PLUS-EXT OR FLEX-CARE-PLUS-EXT-CO (UP TO 23.9 HOURS OF SERVICES AND SUPPORTS) (SCORES MOSTLY 1 & 2)

Amount of Flex Care Services Requested: Ch

What are the specific needs and behaviors to be assessed in setting?: __________________________________________________________

What are the expected outcomes from Level of Flex Care Services requested?: _______________________________________________

What is the plan for transition?: _____________________________________________________________________

oose an item.

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Alternative Options: Flex Care Services are limited and a referral cannot be guaranteed. Clinical teams should have alternative

plans/services that may meet the member’s needs. Please remember that a member can only be on one MMIC

funded housing/treatment waitlist at any given time. Please identify alternative plans/services being explored:

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Signature Page Clinical Team has reviewed the Flex Care Program with member and is aware that Flex Care Services are not long term

housing. Flex Care is intended to be a short term environment focused on transition into a community of the

member’s choice.

Person Completing Assessment: Title: Date:

Member/Guardian Name: Signature: Date:

Clinical Coordinator: Signature: Date:

Clinical Director: Signature: Date:

Prescriber: Signature: Date:

FLEX CARE APPLICATIONS ARE VALID FOR A PERIOD OF 90 DAYS FROM THE DATE THEY WERE ACCEPTED.

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