CCH 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?
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Yes
No
Patient understands that CCH will provide the patient's medical and nursing care during stay.
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Yes
No
Patient understands that CCH is not able to provide transitional housing options at discharge.
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Yes
No
Today's Date
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Month
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Patient Full Name:
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DOB
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Year
SSN
Medicaid/Medicare #
Patient Phone Number
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Area Code
Phone Number
Requesting Provider or Social Worker
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First Name
Last Name
Direct Contact Number
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Area Code
Phone Number
Hospital/Referral Source
All Health Network
Centura-Castle Rock Adventist
Centura-Littleton Adventist
Centura-Other
Centura-Parker Adventist
Centura-Porter
Centura-St. Anthony
Co Community Health Alliance
CO Health Network
Colorado Access
Colorado Coalition (CCH) / Internal
Crossroads Shelter
Denver Health
Denver Health-Eastside Clinic
Denver Health-Hospital
Denver Health-Other
Denver VA (veteran affairs)
Elevation Foot and Ankle
Encompass Rehab
Frisco clinic
Golden Clinic
HCA-Clinic
HCA-Medical Center of Aurora
HCA-North Suburban Medical Center
HCA-Other
HCA-PSL
HCA-Rose Medical Center
HCA-Sky Ridge Medical Center
HCA-Swedish
Health Solutions
Kindred Hospital
Lakewood Rehab
North Range Behavioral Health
People's Clinic Boulder
Powerback Rehab
Rocky Mountain Cares
Rocky Mtn Cancer Center
Roots and Branches boulder
Samaritan House
SCL-Good Samaritan
SCL-Lutheran Medical Center
SCL-Lutheran Medical Center
SCL-Other
SCL-Platte Valley Medical Center
SCL-St. Joseph
Shelter-Other
UCHealth-Hospital
UCHealth-Other
Vail Clinic
Vibra Rehab
Villa Manor Care Center
West Springs Hospital
Not Listed - Other
Direct Contact Email Address
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What is the patient's primary Respite need and/or diagnosis including ICD-10 and details?
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Please list the patient’s acute or chronic medical and psychiatric needs for potential Respite support. Please be as thorough as possible. Omission of information may result in coordination delays.
Over the age of 60
Unmanaged Diabetes
Chronic Heart Disease (CHF, MI, CAD, etc.)
Immunocompromised
Obesity > 35
Respiratory Illness (COPD, asthma, etc.)
M 1 or M 0.5 hold within 90 days
Psychiatric admission within 90 days
ETOH Withdrawal Concern
Viral/Infection Concerns or Isolation Need? (COVID-19, MRSA, Hep C, VRE, HIV, Influenza, Hep A, TB, or other)
Abnormal labs during most recent admission
Needs support/assistance taking medication
If Viral/Infection Concerns, please provide details:
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)
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Yes
No
Patient can take medications independently? (Manages all medications without help)
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Yes
No
Patient alert & oriented x 3? (Not confused, understands what is going on)
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Yes
No
Patient continent and uses toilet without assistance? (Patient requires no help to go to the bathroom)
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Yes
No
Additional information and needs to be filled out for all patients:
Special dietary needs?
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Yes
No
What diet is needed/Details:
Service animal or pets?
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Yes
No
Details:
Can patient walk up/down a flight of stairs without assistance?
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Yes
No
Details:
Does client need or use oxygen? (Note: Oxygen needs to be coordinated by hospital before discharge)
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Yes
No
Does patient use any assistive device(s) for ambulation? (wheelchair, walker)
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Yes
No
Details:
Has the patient ever been convicted of a felony?
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Yes
No
Is the patient currently on parole or probation?
*
Yes
No
Hospital/clinic referrals
Does patient have minimum of a one-week supply of ALL medications? (Note: we cannot accept someone without this)
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Yes
No
Does client need wound care? (Note: If yes, send wound care instructions and pictures if able.)
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Yes
No
Does the patient have any specialty care or follow-up appointments within the next month?
*
Yes
No
Does the patient have a PCP established we need to coordinate care with?
*
Yes
No
Please upload copy of last Physician Progress Note.
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