Hometown Connect Referral Form

Hometown Connect is a non-profit, philanthropic organization working to address unmet needs in our community. It is our mission to love our neighbors by connecting the most vulnerable and broken-hearted individuals and families in the community to established ministries and resources.

We focus on the most vulnerable social determinants of health that cause physical and emotional gaps that are becoming more prevalent in our hometowns such as homelessness, impact of addiction and drugs, material needs, access to nutritional foods, access to affordable health care and comprehensive follow-up, medication copay assistance, accessibility to mental health help, grief counseling, and social work.

*PLEASE FILL OUT THIS FORM IN ITS ENTIRETY*

ALL INFORMATION IS HIPAA SAFE & YOUR HEALTH INFORMATION WILL NEVER BE SHARED WITHOUT YOUR CONSENT

Referral Information

First NameLast Name

Referral Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referral Phone Number

Referral E-mail

example@example.com

Date of Service *

Date

Client Information *

First NameLast Name

Client Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Address Type *

If Other Please Explain

Gender*

Who Does the Referral Live With?*

Client Date of Birth*

Date

Client Phone Number*

Social Security #*

Insurance Provider & Policy Number

Primary Care Physician

Has the client seen a Physician outside of a hospital setting in the last 6 months?

Has the client been to the emergency room or had an inpatient hospital stay in the last 30 days?

When was the last time you received medical care?

Marital Status*

Race*

Highest Level of Education

County*

Is the Referral receiving any other assistance? Private, Government or Other? Please list all that are applicable. *

What assistance if any are you currently receiving for shelter?*

What assistance if any are you currently receiving for food insecurity?*

What assistance if any are you currently receiving for medications?*

What assistance if any are you currently receiving for medical care?*

What assistance if any are you currently receiving for clothing?*

Are you a Veteran or served is the Armed Forces?*

Have we assisted anyone you are related to? (Name & Assistance)*

Is the Referral Disabled?*

Yes. I am legally disabled.Yes. I am disabled but my disability doesn't meet the legal definition of "disabled".No

Employment Status*

Employment Location*

If Unemployed Date of Last Day Worked*

Monthly Household Income*

Number of Individuals in the Household*

Do you Own or Rent Your Home?*

What is your Rent or Mortgage Payment?*

If homeless where are your currently living?*

Primary Reason for Referral*

Please Add As Many Details and As Much Information As Possible

Do you have an emergency contact you would like to list on file?

Relationship to Client

Emergency Contact Phone Number

Please include if anyone who you are giving us permission to discuss information about your individual care plans, resources, and medical information if needed:

Patient Consent to Treat and Hometown Connect Agreement of Care Plan

Hometown Connect and Hometown Healthcare role is to support patients of the system in making shared decisions with their provider about their health and wellbeing. The ministry goal is to empower their patients with the necessary tools and resources to self-manage their health and wellbeing. Our integrated care team involves various professional to help coordinated whole person care and support. Our team of doctors, pharmacist, nurses, social workers, pastors and community health workers (CHWs) are all connected to help support your needs. A CHW is a representative of the medical team and any information shared with a CHW by a patient that is relevant to their health may also be shared with the patient's healthcare provider.

CHW's roles:
• Conduct home visits;
• Perform assessments of patient and family needs for information about mental health, health, and social services;
• Provide information/education about services and provider referral information to patients and their families;
• Act as a liaison between patients, their families, and providers;
• Report to network members the specific characteristics of conditions that impede patients from obtaining available services;
• Document activities, service plans, and results in an effective manner while strictly adhering to all policies and procedures;
• Manage medication needs (including communications with pharmacy, medication scheduling, adherence barriers, side effects, etc.); and
• Assist patients in setting and achieving personal health goals.

*Please note:
• CHWs cannot provide direct transportation for patients but can assist with linkage to public and private transportation services; and
• CHWs cannot accept patient-related phone calls after hours or on weekends but work with local emergency services for acute needs and mobile services.

Patient's Rights
• To be treated in a respectful, non-judgmental manner, in accordance with harm reduction principles;
• To receive supportive services that will help the patient achieve their health goals;
• To receive services in a safe and welcoming environment;
• To have any information shared remain confidential (the only time a CHW will report information against the wishes of a patient is if there are safety concerns for the patient or others);
• To participate in program development by providing feedback about services; and
• To discontinue services at any time.

Patient's Responsibilities
Patients of the healthcare system will agree to work with their assigned Community Health Worker to make shared decisions about their health. In so doing, the patient will agree to the following guidelines:
• To provide the CHW with the information necessary to ensure the patient receives proper services;
• To treat staff, interns, volunteers, and other patients with respect (i.e. act in a non-disruptive and non-threatening manner to others);
• To honor the confidentiality of other patients;
• To communicate with the CHW about any potential safety risks in the patient's home (such as active use of substance abuse, violence in the home, etc.);
• To actively work in partnership with the CHW to develop a plan to achieve patient health goals;
• To understand that the CHW is required to communicate patient health updates (progress and concerns) with the healthcare team; and
• To understand that they can meet with the CHW before/after or during patient visits at the clinic and in the community or at the patient's home (the CHW may attend patient doctor's appointments if the patient would like).

If it is necessary for the patient to cancel a scheduled appointment with a CHW, the patient will do so at least 24 hours prior to the scheduled time. If a scheduled appointment is not canceled as indicated, the CHW will contact the patient to reschedule the appointment as soon as possible.

If at anytime the patient chooses to end participation in the program, the decision will not affect their relationship with their provider and healthcare team. The patient can still receive any necessary medical care. The program also reserves the right to dismiss a patient from the program at any time (due to lack of engagement, disrespect, safety concerns, or any violation of this agreement contract).

If you have any concerns regarding the services you are receiving in the program, you may contact CHW.Equity@ky.gov. We will do our best to accommodate you.

By signing this document, you are agreeing to receive medical care through Hometown Healthcare and Hometown Connect platform of integrated services, and consent to treat for all care coordinated by the care team. Any applicable services rendered maybe billed to an insurance payer based on income verfication and ability of client to pay for services rendered but Hometown Connect will work to provide all necessary services regardless of the client's ability to pay and based on verified income in the home.

Signature

Appointment

Please verify that you are human*

HOMETOWN CONNECT