Swan House Admission Criteria

Admission Criteria:

  1. HIV/AIDS and
  2. Evidence of no communicable TB and
  3. The need for a nurse 24 hour caregiver assistance as evidenced by any one of the following:
    • The need for daily/hourly medication assistance
    • The need for assistance with ADL’s
    • Severe dementia or behavioral issues that contribute to the decreased management of any of the above issues
    • Insurance coverage: Medicaid eligibility or private insurance that will contract for needed services
    • Method of payment for Room and Board

Other assessment considerations for Swan House include:

  • History of behavior that may jeopardize the safety and comfort of current residents
  • Psychiatric instability and resulting behaviors that are not able to be managed by Our House staff
  • Current and history of violent/disruptive behaviors related to substance use---assessment includes ability/willingness to participate in care plan

Resident Selection Process:

Our House manages a wait list for both Our House and Swan House. Referrals are taken by the Director of Social Services. The following information is obtained: demographics, income and insurance verification, provider’s names, general medical issues, mental health and addiction needs, living situation, level of functioning with activities of daily living, history of criminal/violent behavior, and how medical care needs are being met. While Our House acknowledges the chronological order in which people are referred and put on the wait list, priority may be given to someone who has acute medical needs with no appropriate care being delivered in current living situation. Priority may be given to someone with low income and access to fewer resources. Selection may also be determined by the Swan House caregivers’ ability to manage a person’s level of care. Swan House does not discriminate against any person on the basis of race, color, gender, gender identity, marital status, sexual orientation, age, heritage, ancestry, national origin, political ideology, religion or creed.

Pre-Admission Assessment:

If a person is determined clinically appropriate for admission, then a pre-admission assessment will be arranged. Pre-admission assessments are done with the person by a social worker, nurse, and Swan House resident care manager. Occupational therapy is consulted, as well as prior caregivers, family, primary care physician, and disability case manager. This may happen at the facility, or offsite at the hospital, a person’s home, etc. The assessment includes current and past medical history, combined with mental health and substance use assessment. The purpose of the assessment is to determine whether the person’s care needs can be met by the provider. At this time the person is required to provide signature indicating receipt and understanding of the following:
  • Room and Board obligations
  • Medication management policy
  • Resident Rights Policy
  • General house rules
  • A written copy will be placed in the resident’s chart upon admission.

Within 24 hours of admission, caregiver staff review the following policies and resident is required to provide signatures to indicate receipt and understanding of the following:

  • Admission Agreement
  • Grievance Procedure
  • Consent Form (for use of name and photograph—this is optional)
  • Privacy Practices
  • Notification Form (people to be notified in case of illness/death)
  • Fire Evacuation Procedure

Based on comprehensive pre-admission and admission assessments, the following may occur:

  • Behavior contract and/or care plan
  • Plan for recovery support
  • Immediate enrollment in mental health services
  • Advocacy by caregiver staff with providers for symptom management regarding unstable health issues

Misc.

Our House recognizes that people living with HIV may struggle with severe mental health and addiction problems that significantly impact their ability to qualify and receive appropriate housing and healthcare services. Our House is committed to being tolerant and patient with people who are working through their long-term struggles with these issues. While flexibility is practiced whenever possible, staff use clinical discretion in considering involuntary move-out. Involuntary move-out may be initiated based on the following circumstances:
  • Resident’s level of care exceeds that which can be offered at Our House
  • Resident is not physically present on site to utilize the services provided
  • Repeated, active substance use that results in behavior that substantially interferes with rights of other residents
  • Inappropriate behavior that repeatedly and/or significantly interferes with rights of other residents such that it becomes a danger to themselves or others
  • Non-payment of Room and Board with no willingness to participate in payment arrangements