TABLE 3.

Functional Status/Service Need Eligibility Criteria

Continuity in Care	Patient discharged from the geriatric rehabilitation service of a municipal hospital for the indigent after receiving some rehabilitation training there
Continued Care	Patient who has been in a rehabilitation hospital for at least a week is about to be discharged to a noninstitutional setting, and is not leaving the hospital against medical advice
BRI Protective Service	Person mentally incapable of adequately caring for self or interests who is living in the community without the support of an informal caregiver
Congestive Heart Failure	Person with chronic congestive heart failure who is receiving medical care in the outpatient clinics of a hospital
BRI Home Aide	Patient about to be discharged from a geriatric rehabilitation hospital to a noninstitutional setting who is not already receiving organized home aide, homemaker, or visiting housekeeper services from a community agency
Highland Heights	Functionally disabled or medically vulnerable person in need of the specialized architectural features or ancillary services of Highland Heights and who, if applying alone, is not in need of help transferring either out of or into bed, or of 24-hour-a-day supervision
Chronic Disease	Patient who is either in an ambulatory care facility or about to be discharged from a hospital, who is living in, or will be discharged to, a noninstitutional setting, and who will need assistance for at least three months with regard to bathing, dressing, walking, cardiopulmonary conditions, or arthritis, but will not need skilled nursing service, 24-hour-a-day supervision, or kidney dialysis
Worcester	Person living in the community with some level of service need who primarily receives services from informal sources, or person institutionalized who has the potential to return to the community
Section 222 Day Care	Person who needs health care services to restore or maintain functional ability but not 24-hour-a-day supervision
Section 222 Homemaker	Patient discharged from a hospital in last two weeks after a stay of at least 3 days who needs health care services to restore or maintain functional ability but not 24-hour-a-day supervision
Wisconsin CCO/Milwaukee	Person who is at risk of institutionalization (a score of 20 or less on the Geriatric Functional Rating Scale) as determined by the project
Alarm Response	Medically vulnerable or functionally impaired public housing tenant living alone in an apartment without a built-in emergency alarm and response system
Georgia	Person who was previously institutionalized, had applied to a nursing home within the last month, or was certified as eligible for Medicaid-sponsored nursing home care by the Georgia Medical Care Foundation
Triage	Person in an unstable situation, characterized by medical/social problems, a poor informal social support system, environmental problems, or financial problems, who is in need of case management, health education, medical and social services, and who, if institutionalized, has the potential for deinstitutionalization
Chicago	Person who is homebound, impaired in ADLs, and in need of medical and social services, but not of 24-hour-a-day supervision
On Lok	Person who is qualified for 24-hour skilled nursing or intermediate care as determined by the project
Project OPEN	Cognitively aware person who has a medical problem, needs assistance to function independently, and meets one of the following conditions: has been in a hospital or skilled nursing facility, or identified as needing skilled nursing care, in the last 30 days; has suffered a personal loss in the last year; requires assistance with personal care; or, is judged by the interviewer to be having difficulty in living independently
Health Maintenance Team	Chronically ill or disabled person who can be maintained at home with periodic health care at the nonskilled level, who wishes to remain in own home, who would benefit from project services, and who cares for self or has nonproject care provider during the nights, weekends, or holidays
Home Health Care Team	Chronically disabled or terminally ill person rendered homebound (unable to be transported in a private care or taxicab) by his/her physical condition who wishes to receive medical care at home, and has at least one family member or friend willing to participate in his/her care
New York City Home Care	Chronically ill person who needs help with leaving the house, walking stairs, dressing, or bathing, and whose needs can be met with 8 to 20 hours of homemaker/personal care services per week
San Diego	Person who is unable to maintain self at home without assistance, at risk of long-term institutional placement or frequent acute hospital admissions, or in need of long-term care but unable to receive traditional home health because of a stabilized chronic or nonhomebound status
Florida Pentastar	Person at risk for institutional placement within a year who is in need of project services
Nursing Home without Walls Downstate, Upstate	Person who is medically eligible for Medicaid-sponsored nursing home care according to New York State standards (a score of 60 or more on the DMS-1) as determined by the project
South Carolina	Nursing home applicant who is certified as eligible for Medicaid-sponsored nursing home care as determined by a mandatory nursing home preadmission assessment by the project
Channeling Basic, Financial	Person impaired in two or more ADLs, three IADLs, or one ADL and two IADLs who has two or more unmet needs or a fragile informal support system, and who, if institutionalized, is certified for discharge within three months
Acute Stroke	Victim of acute stroke
ACCESS Medicare/Private Pay, Medicare/Medicaid	Person in need of 90 or more days of long-term care who requires an aggregate of skilled nursing care as determined by the project
Post-Hospital Support	Hospital discharge who has a problem which is expected to last at least a year, who is qualified for skilled nursing care (a score of 180 or more on the DMS-1) as determined by the project, and who has a nonpaid caregiver available