• Anthem Blue Cross
  • Health Net
  • L.A. Care Health Plan
  • Blue Shield Promise Health Plan
  • Molina Healthcare

CareKit Forms

Last Revised: Background Information: This assessment is designed as a tool for you, as Lead Care Manager, to assess a member’s health needs and help the member participate in the Enhanced Care Management benefit. Today and over the next 1-3 visits, you and the member will complete this assessment together, and from there develop goals and next steps that support the member’s overall health and wellness.

LA County Enhanced Care Management (ECM) Comprehensive Assessment

Pre-Assessment

Indicate if you used any of the following, recently completed assessments or tools to complete/inform this assessment. The Lead Care Manager should incorporate findings from all available assessments. Assessments do not replace this comprehensive assessment but should inform the development of the care plan.

ACEs or PEARLS
Needs Evaluation Tool

The Needs Evaluation Tool is used by DMH

(Pregnant/Postpartum) CPSP Assessment
(Justice Involved) Health Risk Assessment
(Justice Involved) Re-entry Care Plan
Population of Focus
Is anyone else in the family enrolled in ECM?
Identity & Language
Interpreter needed
Nationality / Tribe / Ethnicity
Relationship Status
Veteran/Discharged from U.S. Armed Forces?
Contact Information
Is in-person contact ok?

ECM preferred contact is in-person.

Do you have any cultural, religious, and/or spiritual beliefs that are important to your family's health and wellness?
In general, would you say your health is:
Compared to one (1) year ago, is your health:
How many times have you been to the emergency room in the past 6 months?
How many times have you been a patient in the hospital in the past 6 months?
In the last 12 months, how many times have you been in a nursing home, rehab, and/or recuperative care?
Do you know who your regularly assigned healthcare providers are?
Do you have a provider for women's health?
Have you had a dental visit in the past 12 months?
Have you been told by a doctor or medical professional that you have any medical conditions?
Sensory Health
Do you have trouble with your vision?
If you have diabetes, have you had a Diabetic Eye Exam done in the last year?
Do you have trouble with your hearing?
Preventative Care Vaccines
COVID-19 vaccine received?
Flu vaccine received?
Tetanus vaccine received?
Pneumonia vaccine received?
Shingles vaccine received?
Need support getting vaccinations?
Preventative Care Screenings

What medications (including birth control, over-the-counter medications, vitamins etc.) are you currently taking?

Are you having any trouble getting or filling your medications?
Were there any days you did not take your medications as prescribed (Missed/Forgot)?
Do you need help taking your medicines?

Do you need help with any of these actions?

Do you need help with taking a bath or shower?
Do you need help with going up the stairs?
Do you need help with eating?
Do you need help with getting dressed?
Do you need help with brushing teeth, brushing hair, or shaving?
Do you need help with making meals or cooking?
Do you need help with getting out of a bed or a chair?
Do you need help with shopping and getting food?
Do you need help with using the toilet?
Do you need help with walking?
Do you need help with washing dishes or clothes?
Do you need help with writing checks or keeping track of money?
Do you need help with getting a ride to the doctor or to see friends?
Do you need help with doing house or yard work?
Do you need help with going out to visit family or friends?
Do you need help with using the phone?
Do you need help with keeping track of appointments?
Getting all the help needed with above?
Have you fallen in the last month?
Are you afraid of falling?
Do family/friends express concerns about ability to care for self?
Assistive Devices & Medical Supplies
Do you experience pain?
Currently pregnant?
Given birth in last 12 months?

Includes live birth, stillbirth; miscarriage (SAB - Spontaneous Abortion), or an abortion induced for medical reasons (TAB - Therapeutic Abortion).

Planning to become pregnant?
Has a healthcare or mental health provider ever told you that you have a mental health diagnosis (including postpartum depression or postpartum anxiety)?
Over the past 30 days, how many days have you felt lonely?
Over the last two weeks, how often have you been bothered by any of the following?
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Thoughts of being better off dead or hurting yourself?
Over the last two weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge?
Not being able to stop or control worrying?
Are you interested in getting support for frightening/traumatic events?
Have you had any changes in thinking, remembering, or making decisions?
In the past month, have you felt worried, scared, or confused that something may be wrong with your mind or memory?
Current or Past Mental Health Provider

Use the declined checkbox to skip the substance-use questions when the member declines this section.

In the past 6 months, how often have you used the following?
Alcohol
Nicotine Products (cigarettes, vaping, chewing tobacco)
Prescription drugs not as prescribed
Marijuana or products with THC
Other substances
Have you ever felt you ought to cut down on drinking or drug use?
Are you currently or have you received treatment for substance use?
If any safety concerns for the member or their family, consult with the clinical consultant and supervisor.

Ask only if this information is not already available to the ECM Provider Team.

Has a healthcare provider ever told you or your family that you had a developmental delay, disability, or brain injury impacting ability to think clearly? (e.g., TBI, autism, ADHD, learning disability)

How the member manages health forms and medical-visit questions.

Do you need help filling out health forms?
Do you need help answering questions during a doctor's visit?
What is your current housing condition?
Are you worried about losing your housing?
Is anyone currently helping you with your housing support?
Can you live safely and easily around your home?
Safety
Do you feel physically and emotionally safe where you live?
Is anyone staying in home without permission?
Are you afraid of anyone or is anyone hurting you?
Is anyone using your money without your OK?
Food Security
Have you or other adults in your household ever cut the size of your meals or skip meals because there was not enough money for food?
How often are you hungry or don't eat because of not enough food?
Do you eat less than you feel you should because there is not enough food?
Social Connections and Support
Who do you live with? (select all that apply)
How often do you see/talk to people you feel close to?
Are you caring for anyone and/or any pets?
Family Member/Individual Supports (Including Caregiver Resources)
Do you have family/friends/others willing to help when needed?
Do you have a caregiver assisting you?
Do you ever think caregiver has difficulty giving you all the help you need?
Do you have an In-Home Supportive Services (IHSS) worker?
Current benefits and services (select all that apply)
Do you sometimes run out of money for food, rent, bills, medicine?
What is your current work situation?
Are there any concerns or challenges with your job?
Are you receiving any services from any of the programs below?
In the past 12 months, have you been involved with the following:
Have you spent 2+ nights in jail/prison/detention in past year?
Ever associated with gang members or been involved in one?

Life-planning documents, authorized representatives, and information needs.

Do you have a life-planning document or advance directive in place?
Do you have an authorized representative to speak on your behalf?
Do you want information on these topics?

From our meeting today what comes to mind as your top 2-3 goals for your health, wellness and social and/or living situation for the next 3-6 months?

Primary needs identified from the assessment and agreed next steps.

Next Steps

Next StepsPerson Responsible
LA County ECM Comprehensive AssessmentForm Code: PL1860 0324As of 3/1/2024