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Older Adults Healthy Results
REFERRAL FORM
https://acphd.org/older-adults-
healthy-results/
Fax referrals to: 510-273-3700
If you do not get confirmation of receipt,
send SECURE email to
PHNOlderAdult@acgov.org
For questions please call 510-577-7037
**PREFERRED: PLEASE INCLUDE A PROBLEM LIST, RECENT CLINIC NOTE OR DISCHARGE
SUMMARY, AND MEDICATION LIST**
Older Adults, Healthy Results is a home-visiting, public health nurse case management program that works with clients who
are having trouble managing complex health conditions due to psychosocial challenges.
Eligibility criteria:
60 years of age or older
Very low income
Medically complex (2+ medical conditions)
At least one functional impairment
Have decision-making capacity (or surrogate)
Agree to accept case management services
We do NOT accept the following referrals:
Primarily psychiatric or substance abuse needs
Have a need for urgent or daily intervention
In immediate need of placement to a higher level of care
End-stage of disease and hospice-eligible
Already receiving comprehensive case management
**Note: There may be a delay between referral and intake. Older Adults, Healthy Results maintains a waitlist.
Referred clients will be contacted when space is available**
Client name:
Phone:
DOB:
Contact person: SSN:
Phone: Preferred language:
Address: ________________________________________________________________________________________ Street City State Zip
Problems to be addressed:
Desired goals for RN case management:
Other referrals made or services currently received:
IHSS
APS
Home health
PACE (CEI, On Lok)
Case management (ECM, MSSP)
VA
CalAIM community supports (pls specify):
_________________________________
_________________________________
Other: _____________
___________________
___________________
MEDICAL CONDITIONS: Medical provider: Phone:
Fax:
Insurance:
☐ Medi-Cal - SOC: $_________
☐ Medi-Cal/Medicare
☐ Other: __________________
MediCal managed care plan:
☐ Alameda Alliance for Health
☐ Kaiser
BEHAVIORAL HEALTH:
Referrer Name: Phone:
Affiliation/agency: Fax: