PASRR LEVEL II INDEPENDENT BEHAVIORAL HEALTH COMPREHENSIVE EVALUATION
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- Lily Phelps
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1 Assessment Date DEMOGRAPHIC INFORMATION Medicaid Number: Recipient Name: (first, middle, last) Bayou Health Plan: Age: DOB: Ethnicity: Gender: Gender Expression: Marital Status: SSN: LOCUS: (date and score) PRIMARY DIAGNOSIS: Facility/Agency/Individual Requesting Placement (please include contact person, phone#, and fax to send determination): Current Location of the Individual: Type of Referral: Pre-admission; Resident Review; Extension Request FACE TO FACE EVALUATION TYPE OF EVALUATION DESK REVIEW REASON FOR DESK REVIEW (one of the following 12 months prior to receipt of the referral) an independent assessment from the 1915i system pre-bayou Health implementation (12/1/15): date of assessment *Please attach COMMENTS: a Bayou Health Behavioral Health Assessment Adults post Bayou Health implementation (12/1/15): date of assessment *Please attach a PASRR Level II evaluation is on file: date of assessment *Please attach NO EVALUATION COMPLETED, SENT BACK TO OBH REASON FOR SENDING BACK TO OBH the individual does not have a serious mental illness Categorical Decision Type of Categorical Decision (check if applicable): Terminal illness Severe Physical illness Delirium Primary Dementia Convalescent Care Emergency/Protective Services Respite Services COMMENTS: DOCUMENTS REVIEWED/INDIVIDUAL INTERVIEWS The following items were available/reviewed as part of this screening (attach all records reviewed): Medical H&P Functional Assessment Psychiatric Evaluation Psychosocial Evaluation Comprehensive Medications Psychological Testing Results Progress Notes Additional Labs or Consults: Other The following individuals were interviewed: Individual Family/significant other (specify) Legal representative/guardian/conservator (specify) Other agency for interdisciplinary coordination (specify) Other BEHAVIORAL HEALTH HISTORY I. CHIEF COMPLAINT (Major symptoms, difficulties, and/or Issues as they relate to behavioral health in recipient s own words/quoted.) OBH-PASRR Level II Assessment-FINAL v.3 (10/2015) Page 1 of 6
2 PRESENTING PROBLEM/HISTORY OF PRESENT ILLNESS (Including recipient s reason for seeking services, precipitating factors, symptoms, II. behavioral and functioning impacts, onset/course of issues, current behavioral health providers, services sought and recipient expectation.) CURRENT BEHAVIORAL HEALTH PROVIDER NAME: PHONE NUMBER: III. PAST PSYCHIATRIC HISTORY (First onset of illness, past diagnostic and treatment history, medications, hospitalizations-date, length, reasons, & facility): Prior Outpatient Mental Health Treatment: No; Yes; Detail: Psychiatric Hospitalizations: No; Yes; Detail: Additional History/Comments: IV. SUBSTANCE ABUSE/DEPENDENCE (Past use of primary, secondary & tertiary current substance, incl. type, freq, method & age of 1st use.) Check any/all that apply in past 12 months: Alcohol Use; Illegal Drug Use; Injected Drug Use ; Tobacco Product Use; Prescription Drugs Abuse; Non-Prescription (OTC) abuse; Alcohol and/or Drug Overdose; Alcohol and/or Drug Withdrawal; Problems caused by gambling; Trouble stopping any substance Substance Abuse Treatment History: None; Outpatient; Intensive Outpatient; Residential/Inpatient:; Detox; SUBSTANCE TYPE Include all use in last 30 days. AGE OF 1ST USE YEARS IN LIFETIME DAYS IN PAST 30 V. CURRENT MEDICAL CONDITIONS (Check all that apply) DAYS SINCE LAST USE AMOUNT PHYSICAL/MEDICAL HISTORY Meets Medical Eligibility for NF placement as determined by the Level I Authority Yes No ROUTE OF ADMINISTRATION Pregnant Due date: Prenatal care: None Reported Congestive Heart Failure Asthma Seizure Cancer Underweight High Blood Pressure Stroke Emphysema Cirrhosis Chronic Pain Overweight Heart Disease Diabetes Epilepsy Digestive Problems Thyroid Disease Sexually Transmitted Dz. VI. CURRENT & PAST MEDICATIONS (Including non-psychotropic prescribed medications for last 12 months) Medication Name Dose Freq. Route Current COMMENTS (Reason Prescribed/Response/Side effects/interactions, etc.) VII. ALLERGIES No Reported Drug or Food Allergies; VIII. PRIMARY CARE PHYSICIAN NAME PHONE FAX IX. ADDITIONAL MEDICAL HISTORY (Diagnosis, Pertinent injuries (head trauma), Illnesses; Hospitalizations, Surgery, labs values, status of conditions, etc. including the dates of onset) OBH-PASRR Level II Assessment-FINAL v.3 (10/2015) Page 2 of 6
3 SOCIAL HISTORY X. LEGAL STATUS Current Legal Status: None; Parole; Probation; Charges Pending; Past Legal Status: None; DWI; Prior Arrests; Court-Ordered Outpatient Treatment; AOT; Judicial; Incarcerations; Other; Other; Comment/Detail: Comment/Detail: Prior XI. FAMILY HISTORY (relationship status with relatives, family involvement in treatment, and living status of significant relatives): Custodial Status: Independent Adult; Family Member; Gov t/judicial; Other: (specify) Contact Info: Name: Relation Phone # Adverse Circumstances in Family of Origin: N/A; Poverty; Criminal Behavioral; Mental Illness; Substance Use; Abuse; Neglect; Domestic Violence; Violence; Trauma; Family Stress: Low Stress; Mildly Stressful; Moderately Stressful; Highly Stressful; Extremely Stressful Family Supports: Highly Supportive; Supportive; Limited Support; Minimal Support; No Support Additional Comments: XII. TRAUMA HISTORY History of Trauma: None; Experienced; Witnessed; Abuse; Neglect; Violence; Sexual Assault; XIII. LIVING SITUATION (Current status and functioning) a. Primary Residence: Own Home; Apartment; Relative s Home; Group Home; Homeless; Nursing Facility; How long at current residence? Family/Household Composition: Source of meals/food: Means of transportation: Additional Comments: (Include psychological and social adjustments made to disabilities and/or disorders.) b. Needs -List what is needed to improve/maintain daily living situation (Ex. Transportation, ability to cook independently, housing subsidy, money in savings, caregiver resource assessment, etc.) c. Preferences - Include things recipient feels will enhance his/her living situation. d. Strengths -List assets, service options, and resources the person has to meet needs, including available housing options. (Ex. Knows area, applied for housing subsidy, can live with family member, unpaid care-giver resource available, etc.) e. Abilities/Interests Include recipient reported skills, aptitudes, capabilities, talents & competencies that might assist in maintaining or improving living situation. XIV. LEARNING/WORKING AND FUNCTIONAL STATUS a. Employment/Education/Rehabilitation Status: Current source of income: Estimated Monthly Income Amount: Highest Grade or Completed/Degree: Military Status: Military Trauma: No; Yes; Difficulties with Reading/Writing: No; Yes; Estimated Literacy Level: Current Employment Status: Assistive Devices utilized/required: No; Yes; Prior Employment Status: Additional Comments: (Include psychological and social adjustments made to disabilities and/or disorders.) b. Current Status & Functioning (Assess ability to fulfill responsibilities, interact with others, capacity self-care, missed activities, work or school due to health, etc.) Functional Status Impairment: ADLs/IADLs None Minimal Mild Moderate Serious Extreme Mobility Bathing OBH-PASRR Level II Assessment-FINAL v.3 (10/2015) Page 3 of 6
4 Dressing Self-Feeding Personal hygiene & grooming Toilet hygiene Housework Meal Preparation Medication Management Managing Finances Shopping (groceries or clothing) Communication Transportation Comments: c. Abilities/Interests - Include recipient reported skills, aptitudes, talents & competencies that may help maintain or improve socialization & community functioning. CURRENT STATUS XV. MENTAL STATUS EXAMINATION (Circle or Check all that apply) a. GENERAL APPEARANCE Healthy; As stated Age; Older Than Stated Age; Young-looking; Tattoos; Disheveled; Unkempt; Malodorous; Thin; Overweight; Obese; b. BEHAVIOR & PSYCHOMOTOR ACTIVITY Normal; Overactive; Hypoactive; Catatonia; Tremor; Tics; Combative; c. ATTITUDE Optimal; Constructive; Motivated; Obstructive; Adversarial; Inaccessible; Cooperative; Seductive; Defensive; Hostile; Guarded; Apathetic; Evasive; Other/Explain: d. SPEECH Normal; Spontaneous; Slow; Impoverished; Hesitant; Monotonous; Soft/Whispered; Mumbled; Rapid; Pressured; Verbose; Loud; Slurred; Impediment; e. MOOD Dysphoric; Euthymic; Expansive; Irritable; Labile; Elevated; Euphoric; Ecstatic; Depressed; Grief/mourning; Alexithymic; Elated; Hypomanic; Manic; Anxious; Tense; d. AFFECT Appropriate; Inappropriate; Blunted; Restricted; Flat; Labile; Tearful; Intense; g. PERCEPTUAL DISTURBANCES None; Hallucinations: Auditory; Visual; Olfactory; Tactile; h. THOUGHT PROCESS Logical/Coherent; Incomprehensible; Incoherent; Flight of Ideas; Loose Associations; Tangential; Circumstantial; Rambling; Evasive; Racing Thoughts; Perseveration; Thought Blocking; Concrete; i. THOUGHT CONTENT Preoccupations; Obsessions; Compulsions; Phobias; Delusions; Thought Broadcasting; Thought Insertion; Thought Withdrawal; Ideas of Reference; Ideas of Influence; Delusions; j. SUICIDAL/HOMICIDAL IDEATION Suicidal Thoughts; Suicidal Attempts; Suicidal Intent; Suicidal Plans; History of Self-Injurious Behavior Homicidal Thoughts; Homicidal Attempts; Homicidal Intent; Homicidal Plans; k. SENSORIUM/COGNITION Alert; Lethargic; Somnolent; Stuporous; Oriented to: Person; Place; Time; Situation; Normal Concentration; Impaired Concentration; l. MEMORY Remote Memory: Normal; Impaired; Recent Memory: Normal; Impaired; Immediate Recall: Normal; Impaired m. INTELLECTUAL FUNCTIONING (Estimate) Above Avg.; Normal/Avg.; Borderline; Mental Retardation: Mild; Moderate; Severe n. JUDGEMENT Critical Judgment Intact; Impaired Judgment; o. INSIGHT True Emotional Insight; Intellectual Insight; Some Awareness of Illness/symptoms; Impaired Insight; Denial; p. IMPULSE CONTROL Able to Resist Impulses; Recent Impulsive Behavior; Impaired Impulse Control; Compulsions; XVI. RISK ASSESSMENT: Assess potential risk of harm to self or others, including patterns of risk behavior and/or risk due to personality factors, substance use, criminogenic factors, exposure to elements, exploitation, abuse, neglect, suicidal or homicidal history, self-injury, psychosis, impulsiveness, etc. a. Risk of Harm to Self: Prior Suicide Attempt; Stated Plan/Intent; Access to means (weapons, pills, etc.); Recent Loss; Presence of Behavioral Cues (isolation, giving away possessions, rapid mood swings, etc.); Family History of Suicide; Terminal Illness; Substance Abuse; Marked lack of support; Psychosis; Suicide of friend/acquaintance; OBH-PASRR Level II Assessment-FINAL v.3 (10/2015) Page 4 of 6
5 b. Risk of Harm to Others: Prior acts of violence; If yes, when was the most recent violent act? ; Destruction of property; Arrests for violence; Access to means (weapons); Substance use; Physically abused as child; Was physically abusive as a child; Harms animals; Fire setting; Angry mood/agitation; Prior hospitalizations for danger to others; Psychosis/command hallucinations; If yes, is there a history of acting on any commands to harm others? Yes No; c. Risk of Harm to Self or Others Rating: (From LOCUS Risk of Harm Evaluation Parameters.) Minimal; Low; Moderate; Serious; Extreme. As Evidenced By: d. Recipient Safety & Other Risk Factors: Feels unsafe in current living environment; Feels currently being harmed/hurt/abused/threatened by someone; Engages in dangerous sexual behavior; Past involvement with Child or Adult Protective Services; Relapse/decompensation triggers; e. Describe recipient s preferences and desires for addressing risk factors, including any Mental Health Advance Directives or plan of response to periods of decompensation/relapse (Ex. Resources recipient feels comfortable reaching out to for assistance in a crisis.): XVII. CULTURAL AND LANGUAGE PREFERENCES (Language, Customs/Values/Preferences) a. Spiritual Beliefs/Preferences: b. Cultural Beliefs/Preferences: XVIII. PRINCIPAL DIAGNOSES (PROVIDE PRINCIPLE BEHAVIORAL, MEDICAL DIAGNOSES, AND DEVELOPMENTAL DISABILITY) DIAGNOSIS SEVERITY, IF APPLICABLE 1. IDENTIFIED NEEDS RECOMMENDED PLACEMENT The individual has a serious mental illness and requires specialized services in an acute setting. (i.e. acute psychiatric hospital) The individual has a serious mental illness and an alternate setting is recommended (i.e. community based treatment, adult residential facility) (specify setting) The individual has a serious mental illness and meets criteria for nursing home admission recommended on a long term basis recommended on a short term basis (specify duration) RECOMMENDED SPECIALIZED SERVICES (PROVIDED THROUGH MCO) MH SERVICES: ACT CPST PSR -Individual PSR -Group PSH Med Mgt Outpt Therapy (Ind) Outpt Therapy (Fam) Outpt Therapy (Group) SA SERVICES: Residential Tx Halfway House IOP Ambulatory Detox Outpt Therapy (Ind) Outpt Therapy (Fam) Outpt Therapy (Group) OTHER (WITH EXPLANATION) Med Mgt by the NF Services for the visually/hearing impaired RECOMMENDED LESSER SERVICES (PROVIDED OR ARRANGED BY THE NURSING FACILITY) Medication education Short term counseling to adjust to the nursing facility Assistance in obtaining medical appliances and devices Crisis intervention plan/safety plan Speech Therapy Training in ADLs Training in independent living skills Structured leisure activities Occupational therapy evaluation Physical therapy evaluation OBH-PASRR Level II Assessment-FINAL v.3 (10/2015) Page 5 of 6
6 Referrals to other agencies or community programs (please specify) Evaluation for a diagnosis of dementia (Alzheimer s or other organic mental disorder) Audiological evaluation Ongoing evaluation of the effectiveness of current psychotropic medications to target symptoms. Dental evaluation Vision evaluation Interpretive services A guardian / conservator for decisions regarding health and safety Other (with explanation) ADDITIONAL SERVICE RECOMMENDATIONS: INTERPRETATIVE SUMMARY OF FINDINGS/DECISION RATIONALE Describe recipient s global preferences/hopes for recovery, recommended treatments/assessments, level of care, duration. Include clinical/central theme, co-occurring disabilities (to include mental health, substance use, and intellectual/developmental disabilities), environmental and personal supports/needs, justification for placement and service recommendations. SIGNATURE PRINTED NAME OF ASSESSOR SIGNATURE LICENSE NUMBER DATE *BY SIGNING THIS DOCUMENT, I CERTIFY THAT I AM INDEPENDENT OF THE OFFICE OF BEHAVIORAL HEALTH MAKING THE DETERMINATIONS AND THAT I HAVE NO DIRECT OR INDIRECT AFFILIATION OR RELATIONSHIP WITH THE NURSING FACILITY. OBH-PASRR Level II Assessment-FINAL v.3 (10/2015) Page 6 of 6
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