MSSP/Linkages Professional Referral

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MSSP Care Management Criteria

65+
Medi-Cal eligible
Care Managment to reduce the risk of out of home placement
Requires assistance with one or more Activities of Daily Living (ADLs), such as self-care, mobility, toileting, feeding

Linkages Care Management Eligibility Criteria

60+
No income restrictions
Goals that can be met in 6 to 12 months
Require care management assistance due to the onset or worsening of an illness, injury, disability, or major life event such as change in income or loss of a partner, in order to live independently

Referring Party Information

Prospective Client Information

first name		last name
SSN		DOB	Age
location	unhoused resides at the following address
address
city
state	zip
phone		language	interpreter needed
marital status		partner
gender		pronouns
on premises	smokers dogs firearms other

	client has regular paid caregiver		IHSS recipient
IHSS social worker
healthcare	Medicare Medi-Cal w/share of cost
Health Provider
contact	client directly another person	name
		phone
		language	interpreter needed
	client is aware of referral

Participation Readiness Assessment

The client is able and willing to help identify their own needs and participate in care planning.

not at all/unlikely

somewhat

mostly/definitely

The client has a committed support person to participate and follow up with care planning and steps to meet their goals.

not at all/unlikely

somewhat

mostly/definitely

Informal Supports

Needs Assessment

reason for referral

goals client wants to address

health issues affecting client's ability to live independently	exists does not exist not applicable

unmet ADL/IADL client needs	exists does not exist not applicable

recent life changes/events	exists does not exist not applicable

Additional Areas of Concern	emotional health cognitive functioning challenging behaviors other
Describe

client strengths, values and interests

any additional comments

MSSP/Linkages Referral