CCH Respite Care Program

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? *

Yes No
Patient understands that CCH will provide the patient's medical and nursing care during stay. *

Yes No
Patient understands that CCH is not able to provide transitional housing options at discharge. *

Yes No
Today's Date *

Month Day Year
Date
Patient Full Name: *
DOB *

Month Day Year
SSN
Medicaid/Medicare #
Patient Phone Number

Area Code Phone Number
Requesting Provider or Social Worker *

First Name Last Name
Direct Contact Number *

Area Code Phone Number
Hospital/Referral Source
Direct Contact Email Address *
What is the patient's primary Respite need and/or diagnosis including ICD-10 and details? *
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) *

Yes No
Patient can take medications independently? (Manages all medications without help) *

Yes No
Patient alert & oriented x 3? (Not confused, understands what is going on) *

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

Yes No
Additional information and needs to be filled out for all patients:
Special dietary needs? *

Yes No
What diet is needed/Details:
Service animal or pets? *

Yes No
Details:
Can patient walk up/down a flight of stairs without assistance? *

Yes No
Details:
Does client need or use oxygen? (Note: Oxygen needs to be coordinated by hospital before discharge) *

Yes No
Does patient use any assistive device(s) for ambulation? (wheelchair, walker) *

Yes No
Details:
Has the patient ever been convicted of a felony? *

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) *

Yes No
Does client need wound care? (Note: If yes, send wound care instructions and pictures if able.) *

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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CCH Respite Care Program

Current Level of Function and Need

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

Hospital/clinic referrals