Fillable AIDS Connecticut Acuity Index (ACT)

Fill Online, Printable, Fillable, Blank AIDS Connecticut Acuity Index (ACT) Form

Use Fill to complete blank online ACT pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

AIDS Connecticut Acuity Index (ACT)

On average this form takes 33 minutes to complete

The AIDS Connecticut Acuity Index (ACT) form is 8 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 124 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your ACT forms online.

BROWSE ACT FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
AIDS Connecticut
Acuity Index
AIDS CT Acuity Index
1
1/16/18
Acuity Index
Note: Shelters and skilled nursing facilities: Do not complete the Housing section or Interpretations at the end. Do complete the
remaining sections.
Housing
Levels
Tenant Level
0
1
2
3
New
Last
Active
Deferred
Rent Payment
Rep Payee/Tenant has not
paid rent for last 6 months
or has only paid on-time 1-3
times in last 12 months
Rep Payee/Tenant has paid
rent on-time 4-6 times in
last 12 months
Rep Payee/Tenant has paid
rent on-time 7-9 times in
last 12 months
Rep Payee/Tenant has paid
rent on-time every month
for the last 12 months
Utility Bill Payment
Tenant has paid utility bills
on-time for 1-3 months in
last 12 months
Tenant has paid utility bills
on-time for 4-6 months in
last 12 months
Tenant has paid utility bills
on-time for 7-9 months in
the last 12 months
Tenant has paid utility bills
on-time for 10-12 months in
last 12 months OR utilities
are included in rent.
Rent Arrears
Tenant has outstanding rent
arrears and is not willing to
set up payment plan
Tenant has more than 6
months of rent arrears and
has set up a payment plan
Tenant has less than 3
months of rent arrears and
is current on payment plan
Tenant has no rent arrears
Utility Arrears
Tenant has outstanding
utility arrears and is not
willing to set up payment
plan
Tenant has less than $1000
in utility arrears and has set
up a payment plan
Tenant has less than $500
in utility arrears and is
current on payment plan
Tenant has no utility arrears
Safe Living
Environment
Tenant had over 5 contacts
with police and/or landlord
regarding disruptive
activities or unsafe
conditions in the unit in last
12 months
Tenant had 3-5 contacts
with police and/or landlord
regarding disruptive
activities or unsafe
conditions in the unit in last
12 months
Tenant had 1-2 contacts
with police and/or landlord
regarding disruptive
activities or unsafe
conditions in the unit in last
12 months
Tenant had no contacts with
police and/or landlord
regarding disruptive
activities or unsafe
conditions in the unit in last
12 months
Lease (include all
leases if tenant
moved)
Tenant has been in
supportive housing less
than 12 months OR has
held a lease less than 12
months
Tenant has been in a
supportive housing program
and has held lease for 12-
23 consecutive months
Tenant has been in a
supportive housing
program and has held
lease for 24- 36
consecutive months
Tenant has been in a
supportive housing program
and has held lease for over
36 consecutive months
Housing Subtotal
Comments:
0
AIDS CT Acuity Index
2
1/16/18
Income and Benefits
Levels
Tenant Level
0
1
2
3
New
Last
Active
Deferred
Stable/Consistent
Source of Cash
Income
Tenant has no
stable/consistent source of
cash income
Tenant has cash income
but it is not
stable/consistent
Tenant has had
stable/consistent cash
income for the last 1 – 6
months
Tenant has had
stable/consistent cash
income for the last 7 or
more months
Benefits
Tenant has no benefits and
has not yet applied for
benefits
Tenant has applied for
benefits but has not yet
received them
Tenant has received all
benefits entitled to for the
last 1-6 months
Tenant has received all
benefits entitled to for the
last 7 or more months OR is
not eligible for benefits
Employment
Tenant is not employed, is
able to work but not seeking
employment OR tenant is
not able to work and has
not received disability
benefits
Tenant is not employed, is
able to work and is seeking
employment/participating in
employment services
Tenant is able to work and
has been employed for less
than 6 months
Tenant is able to work and
has been employed for
more than 6 months OR
tenant is not able to work
and receiving disability
benefits
Debt
Tenant debt greater than 50
percent of income and
tenant is unable to meet
these obligations
Tenant debt is greater than
50 percent of income and
tenant is able to meet these
obligations
Tenant debt is less than 50
percent of income and
tenant is able to meet
these obligations
Tenant debt is between 0
and 10 percent of income
and tenant is able to meet
these obligations
Health (Non-HIV)
Mental Health Care
Use
Tenant has not had contact
with a mental health
provider in the past 12
months
Tenant has contact with a
mental health provider and
has kept less than 50
percent of appointments in
the last 12 months
Tenant has contact with a
mental health provider
and has kept more than
50 percent of
appointments in the last
12 months
Tenant has contact with a
mental health provider and
has kept more than 90
percent of appointments in
the last 12 months OR
Tenant has no need for
mental health services
Primary/Specialty
Health Care Use
Tenant has not had contact
with a primary and/or
specialty health care
provider in the past 12
months
Tenant has contact with a
primary and/or specialty
health care provider and
follows preventive
screening and treatment
recommendations less than
50 percent of the time
Tenant has contact with a
primary and/or specialty
health care provider and
follows preventive
screening and treatment
recommendations 50 to 90
percent of the time
Tenant has contact with a
primary and/or specialty
health care provider and
follows preventive
screening and treatment
recommendations more
than 90 percent of the time
AIDS CT Acuity Index
3
1/16/18
Non HIV
Related
Medication
Adherence
Tenant self-reports never
taking prescribed
medications
Tenant self-reports rarely
taking prescribed
medications
Tenant self-reports
sporadically taking
prescribed medications
Tenant self-reports regularly
taking prescribed
medications OR has no
prescribed medications
Health (continued)
Levels
Tenant Level
0
1
2
3
New
Last
Active
Deferred
Harm Reduction
(such as substance
use, gambling, risky
sexual and other
behaviors)
Tenant does not see
behavior(s) as harmful
Tenant acknowledges
behavior(s) may be harmful
and is contemplating
adoption of harm reduction
goals
Tenant has set harm
reduction goals and has
taken some actions to
achieve them
Tenant has adopted
behaviors to achieve harm
reduction goals OR does
not engage in harmful
behaviors
Supportive Services
and Resources
Connection to
Community Supports
Tenant has no community
supports outside of
supportive housing program
Tenant has limited
community supports and is
not interested in attaining
others
Tenant has adequate
community supports or
has
limited supports but is
interested in attaining
others
Tenant seeks out
community supports and
has many connections
including specialized
services
Crisis Intervention
Tenant has required over 5
crisis interventions in the
past 12 months
Tenant required 3-5 crisis
interventions in the past 12
months and did not work
quickly with case manager
to identify needs/help
Tenant required 3-5 crisis
interventions in past 12
months and worked
quickly with case manager
to
identify needs/help
Tenant required less than 3
crisis interventions in past
12 months and worked
quickly with case manager
to identify needs/help
Life Skills
Tenant is unable to
independently meet basic
needs such as hygiene,
food, activities of daily living
Tenant can independently
meet a few but not all basic
needs such as hygiene,
food, activities of daily living
Tenant can independently
meet most but not all basic
needs such as hygiene,
food, activities of daily living
Tenant is able to
independently meet all
basic needs
Legal
Tenant has outstanding
warrants or has been
incarcerated for more than
90 days in the prior year
Tenant has current charges
or trial pending, or is
noncompliant with criminal
justice supervision
Tenant has been fully
compliant with criminal
justice supervision for less
than 12 months
Tenant has been fully
compliant with criminal
justice supervision for more
than 12 months OR has no
criminal justice supervision
requirements
Mobility &
Transportation
Tenant has no access to
public or private
transportation
Transportation is available,
but is unreliable or
unaffordable
Transportation is available
and reliable, but limited
and/or inconvenient
Transportation is generally
accessible to meet basic
travel needs
Income and Benefits; Health; and Supportive Services and Resources Subtotal
Comments:
0
AIDS CT Acuity Index
4
1/16/18
Acuity Index Family Section
Parenting and Child
Services
Levels
Tenant Level
0
1
2
3
New
Last
Active
Deferred
Childcare
Needs childcare, but none
is available/accessible
and/or child is not eligible.
Childcare is unreliable or
unaffordable, inadequate,
supervision is a problem for
childcare that is available
Affordable subsidized
childcare is available, but
limited
Reliable, affordable
childcare is available, no
need for subsidies
Children’s Education
One or more school aged
children not enrolled in
school
One or more school-aged
children enrolled in school,
but not attending classes.
Parent is unaware and/or
has difficulty addressing
children issues without
significant case
management involvement
Enrolled in school, but one
or more children only
occasionally attending
classes. Parent is aware
and/or has difficulty
addressing children issues
without case management
involvement.
Enrolled in school and
attending classes most of
the time. Parent is aware
and addressing children
issues.
Parenting
There are safety concerns
regarding parenting skills
Parenting skills are minimal
Parenting skills are
apparent but not adequate
Parenting skills are
adequate
Child Welfare
Involvement
High level of mandated
involvement with child
welfare system
Involvement with child
welfare system, no
resolution of matter/case
Recent involvement with
child welfare but matter
resolved and closed
No history of child welfare
involvement OR
involvement was more than
2 years ago
Children with Special
Needs
Children not connected with
services
Children connected with
services but participation
minimal with prompting
Children connected with
services with consistent
participation with prompting
Children with special needs
fully participate in services
OR children have no special
needs
Parenting and Child Services
Comments:
0
AIDS CT Acuity Index
5
1/16/18
HIV Specific Health &
Wellness
Levels
0 1 2 3
Tenant Level
New Last
Service Plan Goal
for Level 0 to 1
Active Deferred
HIV Awareness/
Education
No real knowledge of HIV
and uninterested in HIV
education and support
Tenant has limited
knowledge of HIV and is not
interested in further
education
Tenant has adequate
knowledge of HIV and has
openness to further
education but does not seek
further education or HIV
support
Tenant has substantial
knowledge of HIV and
regularly seeks HIV updates
and connections
HIV Medication
Adherence
Tenant self-reports (or is
known as) never taking
prescribed medications
Tenant self-reports (or is
known as)rarely taking
prescribed medications
Tenant self-reports (or is
known as) sporadically
taking prescribed
medications
Tenant self-reports (or is
known as) regularly taking
prescribed medications OR
has no prescribed
medications
HIV Progression
Advanced HIV, with
debilitating symptoms, multiple
medication (ART) resistance,
including opportunistic
infections and cancer, CD4
<200 and Viral Load >200
Previous
Viral
Load__
CD4
count
Date_____
Most Recent
Viral Load________
CD4 count________
Date_____________
Symptomatic with one or more
conditio
ns requiring treatment
and are high risk for
opportunistic infections and
cancer. CD4 count <200 and
Viral Load >200
Previous
Viral
Load___
CD4
count
Date
_________
Most Recent
Viral Load_________
CD4 count________
Date______________
May or may not experience
HIV symptoms (ie: Flu-like),
and monitor with ART
treatment and CD4 that <500
and Viral Load >200.
Previous
Viral
Load __
CD4
count
Date
________________________________________________
Most Recent
Viral Load_________
CD4count_________
Date____________
Asymptomatic, normal CD4
(500-1500) and Viral Load
(<200) (monitors the
progression)
Previous
Viral
Load__
CD4
count
Date___________
Most Recent
Viral Load_________
CD4 count________
Date___________
Transmission
Infection Risk
(IDU, sharing works,
MSM, commercial sex
workers, rape, non-
professional tattoos,
sex without condoms)
Tenant currently engages in
high-risk transmission
behaviors
Currently engages in
occasional high-risk
transmission behaviors
Tenant has not engaged in
high-risk transmission
behaviors in the last 3
months
Tenant does not engage in
high risk transmission
behaviors for at least 6 months
HIV Specific Health & Wellness
0
AIDS CT Acuity Index
6
1/16/18
Comments:
AIDS CT Acuity Index
7
1/16/18
• Shelters and skilled nursing facilities: The housing section is non-applicable (N/A) Please complete the remainder of the assessment, but do not complete the Acuity
Index Interpretation.
Acuity Index Interpretation
Area Maximum Level Minimum Level Ideal Range
Current Level on
this Assessment
Housing
18
12
16-18
Income and Benefits; Health; and Supportive Services
and Resources
39
26
35-39
Parenting and Child Services
15
10
13-15
HIV Specific Health & Wellness
12
9
10-12
Interpretation:
• All applicable levels fall within the ideal range: Other housing options with community supports should be considered as a short term goal.
• Applicable levels are at or above minimum but not all fall within the ideal range: Other housing options with community-based supports should be considered as a
long term goal.
• One or more levels are below the minimum: Tenant should remain in supportive housing.
• HIV Specific Health & Wellness: If any area fall below a 3 tenant should remain in supportive housing.
Signatures
The information in this assessment was collected in good faith and the information contained in this assessment is as accurate as possible.
Case Manager Signature Date Supervisor Signature Date
0
0
0
0
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

AIDS Connecticut Acuity Index (ACT)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document