| ENTRY SPECIFICATION |
{"name": "CCICM20",
"text": "1. Ability to communicate and understand healthcare needs to obtain services
{"id": "c5410", "text": " Adherence with plan of care with periodic reinforcement needed, (for example,
sporadic untimely medication refills or doses, less than 5 no-shows or
cancellations by Veteran in 12 months)"},
{"id": "c5411", "text": " Inconsistent and sporadic adherences with plan of care, (for example, frequent
untimely medication refills or doses, 5 to 10 no-shows or cancellations in the
past 12 months)"},
{"id": "c5412", "text": " Non-adherence with plan of care and at high risk for decline, (for example,
repeated need for urgent/emergent services, not taking medications, more than 10
no-shows in the past 12 months)"}
]},
(e.g. providers, teams, medication and equipment)",
{"id": "i2479", "type": "IntroText",
"text": "MENTAL HEALTH/BEHAVIORAL HEALTH<br /> When choosing a score and multiple
selections apply, select highest score."
},
{"id": "q8852", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "9. Coping Skills",
"intro": "MENTAL HEALTH/BEHAVIORAL HEALTH<br /> When choosing a score and multiple
selections apply, select highest score.",
"columns": 1,
"choices":[
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
{"id": "c5413", "text": " Adequate coping skills: Generally able to manage life stressors and health
challenges"},
{"id": "c5414", "text": " Mild difficulty with coping: Episodic/situational with potential difficulty for
quick resolution"},
{"id": "c5415", "text": " Moderate difficulty with coping: Utilizing multiple resources without the need
for inpatient treatment"},
{"id": "c5416", "text": " Severe difficulty: Active crisis state with inpatient treatment needed"}
]},
{"id": "q8853", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "10. Mental health symptom severity",
highest score. ",
"intro": "MENTAL HEALTH/BEHAVIORAL HEALTH<br /> When choosing a score and multiple
selections apply, select highest score.",
"columns": 1,
"choices":[
{"id": "c5417", "text": " No Mental Health history"},
{"id": "c5418", "text": " History of MH with no current concerns/symptoms; Active MH symptoms being
adequately addressing in MH treatment"},
{"id": "c5419", "text": " Active MH concerns with disruption to daily functioning"},
{"id": "c5420", "text": " Inpatient psychiatric admissions and persistent or severe disruption to daily
functioning, for example, SI/HI, psychotic symptoms"}
"columns": 1,
]},
{"id": "q8854", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "11. Substance use",
"intro": "MENTAL HEALTH/BEHAVIORAL HEALTH<br /> When choosing a score and multiple
selections apply, select highest score.",
"columns": 1,
"choices":[
{"id": "c5421", "text": " No Substance use disorder history"},
{"id": "c5422", "text": " History of substance use disorder but now in remission; No current concerns"},
{"id": "c5423", "text": " Active substance use with mild disruption to daily functioning (for example,
"choices":[
work, school, home)"},
{"id": "c5424", "text": " Active substance use with severe disruption to daily functioning (for example,
inpatient admission, suicide/behavioral/substance seeking flag)."}
]},
{"id": "i2480", "type": "IntroText",
"text": "SOCIAL<br /> When choosing a score and multiple selections apply, select highest
score."
},
{"id": "q8855", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "12. Living Situation/Housing",
{"id": "c5381", "text": " No difficulites"},
"intro": "SOCIAL<br /> When choosing a score and multiple selections apply, select highest
score.",
"columns": 1,
"choices":[
{"id": "c5425", "text": " Stable housing; No concerns"},
{"id": "c5426", "text": " Stable housing but dependent on support of others"},
{"id": "c5427", "text": " Unstable housing or not suitable to needs (for example, utility disruption,
non-ADA accessible, pest infestation, unaffordable, hoarding, unsafe living
conditions)"},
{"id": "c5428", "text": " No housing/homeless"}
{"id": "c5382", "text": " Mild difficulties (1-2 examples)"},
]},
{"id": "q8856", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "13. Employment/Financial",
"intro": "SOCIAL<br /> When choosing a score and multiple selections apply, select highest
score.",
"columns": 1,
"choices":[
{"id": "c5429", "text": " No employment/financial concerns"},
{"id": "c5430", "text": " Employment concerns/mild financial strain"},
{"id": "c5431", "text": " Employment concerns/moderate financial strain"},
{"id": "c5383", "text": " Moderate difficulties (3-4 examples)"},
{"id": "c5432", "text": " Employment concerns/severe financial strain"}
]},
{"id": "q8857", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "14. Social support/relationships",
"intro": "SOCIAL<br /> When choosing a score and multiple selections apply, select highest
score.",
"columns": 1,
"choices":[
{"id": "c5433", "text": " Generally stable social relationships or engagement with leisure activities"},
{"id": "c5434", "text": " Limited social relationships or moderate engagement with leisure activities"},
{"id": "c5384", "text": " Severe difficulties (1 significant cognitive disorder/decline or 5+ examples)"}
{"id": "c5435", "text": " Limited social relationships or mild engagement with leisure activities"},
{"id": "c5436", "text": " Socially isolated or no engagement with leisure activities"}
]},
{"id": "q8858", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "15. Abuse/Neglect/Violence",
"intro": "SOCIAL<br /> When choosing a score and multiple selections apply, select highest
score.",
"columns": 1,
"choices":[
{"id": "c5437", "text": " No abuse/neglect/violence suspected, reported or confirmed"},
"restartDays": 7,
]},
{"id": "c5438", "text": " History of abuse/neglect/violence"},
{"id": "c5439", "text": " Suspected active abuse/neglect/violence"},
{"id": "c5440", "text": " Confirmed active abuse/neglect/violence"}
]},
{"id": "q8859", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "16. Legal issues",
"intro": "SOCIAL<br /> When choosing a score and multiple selections apply, select highest
score.",
"columns": 1,
"choices":[
{"id": "q8845", "type": "ChoiceQuestion", "required": true, "inline": false,
{"id": "c5441", "text": " No active or past legal issues known or recorded"},
{"id": "c5442", "text": " Past or current legal issues with minimal impact on quality of life"},
{"id": "c5443", "text": " Past legal issues with major impact on quality of life (for example, felony,
multiple charges)"},
{"id": "c5444", "text": " Current/Pending legal issues with major impact on quality of life (for example,
felony, multiple charges)"}
]},
{"id": "i2481", "type": "IntroText",
"text": "MEDICAL/PHYSICAL<br /> When choosing a score and multiple selections apply,
select highest score."
"text": "2. Access to healthcare within VA and/or Community Care (e.g. geographical
},
{"id": "q8860", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "17. Functional (Activities of Daily Living (ADLS)/Instrumental Activities of
Daily Living (IADLs)",
"intro": "MEDICAL/PHYSICAL<br /> When choosing a score and multiple selections apply,
select highest score.",
"columns": 1,
"choices":[
{"id": "c5445", "text": " Independent for ADLs {walking, bathing} and IADLs {cooking, driving, shopping}"},
{"id": "c5446", "text": " Independent for ADLs but not IADLs"},
barriers, transportation, clinic availability and technology availability for
{"id": "c5447", "text": " Requires assistive support for both ADLs and IADLS (1-2 ADLs)"},
{"id": "c5448", "text": " Requires significant support for ADLs and IADLS (3+ ADLs)"}
]},
{"id": "q8861", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "18. Care coordination, complexity and integration",
"intro": "MEDICAL/PHYSICAL<br /> When choosing a score and multiple selections apply,
select highest score.",
"columns": 1,
"choices":[
{"id": "c5449", "text": " Care is coordinated, integrated and no concerns in communication"},
virtual care)",
{"id": "c5450", "text": " Has Primary Care Provider with limited communication/coordination/integration"},
{"id": "c5451", "text": " Has PCP and other providers without evidence of
communication/coordination/integration"},
{"id": "c5452", "text": " Unassigned and/or frequent provider changes without evidence of
communication/coordination/integration"}
]},
{"id": "q8862", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "19. Disease and symptom severity",
"intro": "MEDICAL/PHYSICAL<br /> When choosing a score and multiple selections apply,
select highest score.",
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
"columns": 1,
"choices":[
{"id": "c5453", "text": " No symptom concerns"},
{"id": "c5454", "text": " Well-managed by Patient Aligned Care Team; may experience mild signs or symptoms
with no interference in well-being or daily life"},
{"id": "c5455", "text": " Requires specialty referrals for management; moderate signs or symptoms with
major interference in well-being or daily life"},
{"id": "c5456", "text": " Requires specialty referrals for management; severe signs or symptoms with risk
of permanent deficit or death"}
]},
highest score. ",
{"id": "q8863", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "20. Comorbid medical diagnoses and/or injuries",
"intro": "MEDICAL/PHYSICAL<br /> When choosing a score and multiple selections apply,
select highest score.",
"columns": 1,
"choices":[
{"id": "c5457", "text": " No chronic disease diagnosis and/or injury"},
{"id": "c5458", "text": " At least one chronic disease and/or serious persistent injury"},
{"id": "c5459", "text": " Has 2-3 chronic diseases and/or serious persistent injuries"},
{"id": "c5460", "text": " Has 4+ chronic diseases and/or serious persistent injuries"}
"columns": 1,
]}]
}
"choices":[
{"id": "c5385", "text": " Adequate access to healthcare"},
"printTitle": "Care Coordination & Integrated Case Management (CC&ICM) Complexity Assessment",
{"id": "c5386", "text": " Mild limitations/difficulties (1-2 barriers)"},
{"id": "c5387", "text": " Moderate limitations/difficulties (3-4 barriers)"},
{"id": "c5388", "text": " Severe barriers to adequate access to care (5+ barriers)"}
]},
{"id": "q8846", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "3. Experience with providers and healthcare team",
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
highest score. ",
"columns": 1,
"choices":[
"content":[
{"id": "c5389", "text": " No problems and satisfied with treatment and healthcare team"},
{"id": "c5390", "text": " New patient"},
{"id": "c5391", "text": " Negative experience/dissatisfaction/distrust"},
{"id": "c5392", "text": " Repeated negative experiences"}
]},
{"id": "q8847", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "4. Utilization",
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
highest score. ",
"columns": 1,
{"id": "i2478", "type": "IntroText",
"choices":[
{"id": "c5393", "text": " No admissions or ED visits in the past 12 months"},
{"id": "c5394", "text": " One to two admissions or ED visits in the past 12 months"},
{"id": "c5395", "text": " Three or four admissions or ED visits in the past 12 months"},
{"id": "c5396", "text": " Five or more admissions or four ED visits in the past 12 months"}
]},
{"id": "q8848", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "5. Shared Decision-Making",
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
highest score. ",
"text": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
"columns": 1,
"choices":[
{"id": "c5397", "text": " Consistent engagement in shared decision-making in care planning and treatment
interventions"},
{"id": "c5398", "text": " Frequent engagement in shared decision-making in care planning and treatment
interventions"},
{"id": "c5399", "text": " Occasional engagement in shared decision-making in care planning and treatment
interventions"},
{"id": "c5400", "text": " Minimal or no engagement in shared decision-making in care planning and
treatment interventions"}
highest score. "
]},
{"id": "q8849", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "6. Readiness to change",
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
highest score. ",
"columns": 1,
"choices":[
{"id": "c5401", "text": " Action/Maintenance stages with minimal support needed"},
{"id": "c5402", "text": " Preparation for change with readiness to connect to resources"},
{"id": "c5403", "text": " Contemplation requiring redirection and reinforcement"},
},
{"id": "c5404", "text": " Pre-contemplation and not ready for change"}
]},
{"id": "q8850", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "7. Engagement in goal setting",
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
highest score. ",
"columns": 1,
"choices":[
{"id": "c5405", "text": " Goals are identified, and actively engaged in all steps to achieve goals"},
{"id": "c5406", "text": " Goals are identified, but partially engaged in achieving goals"},
{"id": "q8844", "type": "ChoiceQuestion", "required": true, "inline": false,
{"id": "c5407", "text": " Goals are identified, but no engagement in achieving goals"},
{"id": "c5408", "text": " No goals are identified; No motivation to set goals"}
]},
{"id": "q8851", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "8. Adherence to plan of care",
"intro": "SELF-MANAGEMENT<br /> When choosing a score and multiple selections apply, select
highest score. ",
"columns": 1,
"choices":[
{"id": "c5409", "text": " Adherence with plan of care"},
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