MVP Referral - The Road Home

MVP Referral Form

The MVP is a temporary non-congregate, semi-private, shelter for individuals who are at least 60 years old or who have chronic health conditions.
The MVP is not an assisted living facility or a skilled nursing facility. All clients must be able to manage their medications, be stable medically and psychologically, and be able to complete their own activities of daily living independently. Home health can assist individuals , if ordered by their doctor, but ultimately the clients need to be independent in their care. All home health orders need to be reviewed prior to acceptance.
Space and beds are awarded based on medical vulnerability and age. All applicants are evaluated based on chronic medical conditions, sheltered or unsheltered status, exacerbation of health conditions, recent hospitalizations, and age. Those who are most vulnerable are offered space first.
Our goal for all individuals in the MVP is to assist them in finding stable independent housing based on their unique needs.
We offer medical case management, primary care, nursing care, behavioral health, transportation assistance, EMT triage, and housing case management onsite.

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Is this person 60 years or older? *

Does this person have significant underlying health conditions (such as kidney failure, heart conditions, cancer, immune compromised) or in need of recuperative care, as attested to by a medical provider? *

Have you ever worked with a mental health therapist?

Would you like to connect to a mental health therapist at this time?

This individual is not eligible for MVP referral.

Name *

First

Last

Date of Birth *

What is this person's gender? *

Male
Female
Nonbinary
Decline to state

HMIS Client ID

Referring Partner/Agency *

Please specify the Referring Partner *

Referring Partner/Agency Email (Confirmation Email Sent Here) *

What is the name of the Case Manager or individual filling out this form? *

Client Contact Information

Client Email

Is this person sheltered? *

Where are they staying?

Address Line 1

City

State

Zip Code

Does this person have a Medical Provider?

a client a

Name of Medical Provider

Can you / this person accomplish activities of daily living (ADLs)?

If this person has significant underlying health conditions (such as kidney failure, heart conditions, cancer, immune compromised) or in need of recuperative care, as attested to by a medical provider, please provide more information here.

Can this client climb 15 stairs multiple times a day? *

MVP does not have an elevator, if a client struggles with stairs, please mark "No" to this question for safety.

If you are applying for placement into the MVP based on medical conditions, a medical records review must be completed by staff at Fourth Street Clinic. By signing this release, you are providing permission to obtain, access, and /or review your health records.

Authorization to Use and Disclose Health Information of:

Social Security Number

Phone Number

Address

Address Line 1

City

State

Zip Code

This authorization is to release information to:
Fourth Street Clinic and The Road Home

The purpose of this disclosure is:
For medical condition and health history review for placement into the MVP and for coordination of health care while in the MVP.

Specify Dates of Service

(if no date are specified, please allow access to all record dates)

From this Date

To this Date

Please Release the Following Information:

Discharge Summary
Emergency Records
History & Physical
Consultation
Progress Notes
Cardiology Reports
Psychiatric Records
Alcohol/Drug Tx Records
Treatment Plan
Medication List
Other records as specified

This authorization will remain in effect until the date listed or any of the following is true:

A. Your application for the MVP or this authorization is rescinded or revoked by you.

B. Your application is denied, rejected, or has expired (180 days from application submission).

C. You are discharged from the MVP.

OR

D. From the date of this Authorization until this date:

E. Other:

I understand that: Once this facility discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. I may make a request in writing at any time to the Medical Records Department to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR § 524. The Fourth Street Clinic has 30 days to provide a copy of my records. My records are protected and cannot be disclosed without my permission. *Alcohol/drug treatment records are protected by federal rule 42 CFR, part 2. This authorization will remain in effect until the Authorization expires or I provide a written notice of revocation to the Fourth Street Privacy Office.

To be used if facility requests this authorization: I understand that: I may refuse to sign or revoke this Authorization at any time for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of this facility's treatment of me, enrollment in the health plan, or eligibility for benefits. I understand that a revocation will not apply to information that has already been released in response to this authorization. I may make a request in writing at any time to the Medical Records Department to inspect and/or obtain a copy of protected health information maintained at this facility to be used or disclosed as provided in the Federal Privacy rule 45 CFR § 164.524. If l have questions about disclosure of my health information, I can contact the Privacy Officer/Medical Records Department.

BY SIGNING, YOU INDICATE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THESE TERMIS, AND THAT YOU ARE THE PATIENT, THE GUARANTOR, THE PATIENT’S LEGAL REPRESENTATIVE, OR YOU ARE LEGALLY AUTHORIZED TO SIGN THIS AGREEMENT AND ACCEPT THESE TERMS.

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KATZ index of Activities of Daily Living (ADLs)

Bathing *

	Independence: (1 POINTS) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity	Dependence: (0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing
Score	Independence: (1 POINTS) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremityScore Independence: (1 POINTS) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity	Dependence: (0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathingScore Dependence: (0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing

Dressing *

	(1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes	(0 POINTS) Needs help with dressing self or needs to be completely dressed.
Score	(1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoesScore (1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes	(0 POINTS) Needs help with dressing self or needs to be completely dressed.Score (0 POINTS) Needs help with dressing self or needs to be completely dressed.

Toileting *

	(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.	(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.
Score	(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.Score (1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.	(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.Score (0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.

Transferring *

	(1 POINT) Exercises complete self control over urination and defecation.	(0 POINTS) Is partially or totally incontinent of bowel or bladder.
Score	(1 POINT) Exercises complete self control over urination and defecation.Score (1 POINT) Exercises complete self control over urination and defecation.	(0 POINTS) Is partially or totally incontinent of bowel or bladder.Score (0 POINTS) Is partially or totally incontinent of bowel or bladder.

Continence *

	(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable	(0 POINTS)Needs help in moving from bed to chair or requires a complete transfer.
Score	(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptableScore (1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable	(0 POINTS)Needs help in moving from bed to chair or requires a complete transfer.Score (0 POINTS)Needs help in moving from bed to chair or requires a complete transfer.

Feeding *

	(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.	(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.
Score	(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.Score (1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.	(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.Score (0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

Telephone *

	(1 POINT) Is able to at least answer the phone, if not dial or look up other numbers.	(0 POINTS) Does not use telphone.
Score	(1 POINT) Is able to at least answer the phone, if not dial or look up other numbers.Score (1 POINT) Is able to at least answer the phone, if not dial or look up other numbers.	(0 POINTS) Does not use telphone.Score (0 POINTS) Does not use telphone.

Housekeeping *

	(1 POINT) Maintains living space with minimal help, or can at minimum perform daily tasks like dishwashing and bed making.	(0 POINTS) Does not participate in any housekeeping tasks.
Score	(1 POINT) Maintains living space with minimal help, or can at minimum perform daily tasks like dishwashing and bed making.Score (1 POINT) Maintains living space with minimal help, or can at minimum perform daily tasks like dishwashing and bed making.	(0 POINTS) Does not participate in any housekeeping tasks.Score (0 POINTS) Does not participate in any housekeeping tasks.

Medication Management *

	(1 POINT) Is capable of taking their prescribed medication in correct dosages at correct times without reminders.	(0 POINTS) Does not take medications as directed, or relies on others to perform this requirement for them on their behalf.
Score	(1 POINT) Is capable of taking their prescribed medication in correct dosages at correct times without reminders.Score (1 POINT) Is capable of taking their prescribed medication in correct dosages at correct times without reminders.	(0 POINTS) Does not take medications as directed, or relies on others to perform this requirement for them on their behalf.Score (0 POINTS) Does not take medications as directed, or relies on others to perform this requirement for them on their behalf.

Do they require injections that they are able to perform independently? *

Yes, they are able to perform injections independently.
No, they do require injections, but they need assistance administering them.
No, they don't require injections.

Will this client require an ADA accessible living space? *

Yes
No
Unsure

Does this client require supplemental oxygen? *

Does this client require a special diet? *

MVP cannot accomodate special dietary needs, including restrictive allergies.

Does this person require an assistive device? *

Wheelchair
Walker
Cane
They do not require any assistive device

Is there any special information or considerations you would like to communicate to our referral team about this client?

I, (THE SUBMITTER), understand that the answers I provide are accurate to the best of my knowledge and if the client is not independent in these tasks, for their own safety, they will be quickly transferred out of MVP. *

Looking for immediate shelter?

Experiencing a housing crisis?

If you have any other questions

OTHER RESOURCES

VOLUNTEER

OTHER WAYS

ABOUT

STORIES

Looking for immediate shelter?

Experiencing a housing crisis?

If you have any other questions

MVP Referral Form

This individual is not eligible for MVP referral.

If you are applying for placement into the MVP based on medical conditions, a medical records review must be completed by staff at Fourth Street Clinic. By signing this release, you are providing permission to obtain, access, and /or review your health records.

Specify Dates of Service

This authorization will remain in effect until the date listed or any of the following is true:

OR

KATZ index of Activities of Daily Living (ADLs)

ABOUT US

Looking for immediate shelter?

Experiencing a housing crisis?

If you have any other questions

OTHER RESOURCES

VOLUNTEER

OTHER WAYS

ABOUT

STORIES

MVP Referral Form

This individual is not eligible for MVP referral.

If you are applying for placement into the MVP based on medical conditions, a medical records review must be completed by staff at Fourth Street Clinic. By signing this release, you are providing permission to obtain, access, and /or review your health records.

Specify Dates of Service

This authorization will remain in effect until the date listed or any of the following is true:

OR

KATZ index of Activities of Daily Living (ADLs)

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