Activated Respite Care Bridge Housing Program

CCH Activated Respite Care Program

All referrals must be approved by Colorado Coalition for the Homeless staff prior to intake
Patient agrees to have their information shared to coordinate services?*

YesNo
Patient understands that CCH will provide the patient's medical and nursing care during stay.*

YesNo
Patient understands that CCH is not able to provide transitional housing options at discharge.*

YesNo
Today's Date *

MonthDayYear
Date
Patient Full Name*
DOB*

MonthDayYear
SSN
Medicaid/Medicare #
Patient Phone Number

Area CodePhone Number
Requesting Provider or Social Worker*

First NameLast Name
Direct Contact Number*

Area CodePhone Number
Hospital/Referral Source
Direct Contact Email Address*
Is this facility in Denver?*

YesNo
Is this a COVID-19 related referral?*

YesNo
Has Patient been tested yet?

YesNo
Date of Test

MonthDayYear
Date
Location of Test
Result

PositiveNegativePending
Has patient already been vaccinated?

YesNo
Current symptoms

New FeverNew CoughNew Shortness of BreathNew onset loss of taste and/or smell
Please list the patient's acute or chronic medical and psychiatric needs for potential Respite support (please select all that apply)

Above the age of 60Unmanaged DiabetesPsychiatric DiagnosesImmunocompromisedChronic Heart DiseasePsychiatric Admit w/in 90 daysObesity (BMI > 30)ETOH Withdrawal ConcernViral/Infection Concern or Isolation NeedRespiratory IllnessMobility ConcernsOther
Current Level of Function and Need

If answer is no for any of the below, the patient is not eligible.
Patient performs all ADLs 100% independently? (Can feed and dress themselves without assistance)*

YesNo
Patient can take medications independently? (Manages all medications without help)*

YesNo
Patient alert & oriented x 3? (Not confused, understands what is going on)*

YesNo
Patient continent and uses toilet without assistance? (Patient requires no help to go to the bathroom)*

YesNo
Additional information and needs to be filled out for all patients:
Special dietary needs?*

YesNo
What diet is needed/Details:
Service animal or pets?*

YesNo
Details:
Can patient walk up/down a flight of stairs without assistance?*

YesNo
Details:
Does patient use any assistive device(s) for ambulation? (wheelchair, walker)*

YesNo
Details:
Hospital/clinic referrals
Does patient have minimum of 48-hour supply of ALL medications? (Note: we cannot accept someone without this)*

YesNo
Does client need or use oxygen? (Note: Oxygen needs to be coordinated by hospital before discharge)*

YesNo
Does client need wound care? (Note: If yes, send wound care instructions and pictures if able. Patient must be able to do own wound care or wound must be manageable with minimal nursing support.)*

YesNo
Please upload copy of last Physician Progress Note.

Browse Files

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Should be Empty:

CCH Activated Respite Care Program

Current Level of Function and Need

Additional information and needs to be filled out for all patients:

Hospital/clinic referrals