Individual Vulnerability Index Scoring
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More than three hospitalizations or emergency room visits in a year = 1.
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More than three emergency room visits in the previous three months = 1.
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Aged 60 or older = 1.
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Liver disease, cirrhosis of the liver, end stage liver disease = 1.
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Kidney disease, end-stage renal disease, dialysis = 1.
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History of frostbite, immersion foot, or hypothermia = 1.
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HIV+ or AIDS = 1.
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Tri-morbidity: co-occurring psychiatric, substance abuse, and chronic medical condition = 1.
Individuals: Vulnerability Index (VI) Plus Screening Tool
Start Date: ___/ ___/ ____
End Date: ___/ ___/ ____
What is the total length of time in days you have lived on the streets or shelter?
Do you have (or could you get) written documentation that shows the number of days that you have been homeless?
Yes No
Have you (or your spouse or dependent) been diagnosed with a substance abuse disorder, serious mental illness, developmental disability, chronic physical illness or other disabling condition that limits your ability to work or perform daily activities?
Yes No
If yes, do you have (or could you get) written documentation from a medical professional that says that you are disabled?
Yes No
How many times have you been to the emergency room in the past three months?
How many times have you been hospitalized as an inpatient in the past year?
Do you have now, or have you ever had, or has a healthcare provider ever told you that you have any of the following medical conditions?
Kidney Disease/End stage Renal Disease or Dialysis
Yes No Client doesn't know Client Refused Data not collected
History of Frostbite, Hypothermia, or Immersion Foot
Yes No Client doesn't know Client Refused Data not collected
History of Heat Stroke/Heat Exhaustion
Yes No Client doesn't know Client Refused Data not collected
Liver Disease, Cirrhosis, or End-Stage Liver Disease
Yes No Client doesn't know Client Refused Data not collected
Heart Disease, Arrhythmia, or Irregular Heartbeat
Yes No Client doesn't know Client Refused Data not collected
HIV+/AIDS
Yes No Client doesn't know Client Refused Data not collected
Emphysema
Yes No Client doesn't know Client Refused Data not collected
Diabetes
Yes No Client doesn't know Client Refused Data not collected
Asthma
Yes No Client doesn't know Client Refused Data not collected
Cancer
Yes No Client doesn't know Client Refused Data not collected
Hepatitis C
Yes No Client doesn't know Client Refused Data not collected
Tuberculosis
Yes No Client doesn't know Client Refused Data not collected
Have you ever abused drug/alcohol, or been told you do?
Yes No Client doesn't know Client Refused Data not collected
Observer response: Case manager observed alcohol use (daily use)?
Yes No Client doesn't know Client Refused Data not collected
Have you ever used injection drugs or shots?
Yes No Client doesn't know Client Refused Data not collected
Observer response: Case manager observed alcohol use (daily use)?
Yes No Client doesn't know Client Refused Data not collected
Have you ever been treated for drug or alcohol abuse?
Yes No Client doesn't know Client Refused Data not collected
Observer response: Case manager observed alcohol use (daily use)?
Yes No Client doesn't know Client Refused Data not collected
Are you currently or have you ever received treatment for mental health issues?
Yes No Client doesn't know Client Refused Data not collected
Observer response: Case manager observed alcohol use (daily use)?
Yes No Client doesn't know Client Refused Data not collected
Have you ever been taken to the hospital against your will for mental health reasons?
Yes No Client doesn't know Client Refused Data not collected
Observer response: Case manager observed alcohol use (daily use)?
Yes No Client doesn't know Client Refused Data not collected
Observation Question (Safe Haven screening)
Is there a disconnect between the Veteran's apparent mental illness (MI) and awareness of it?
Yes No
Is the applicant appropriately dressed for the weather (i.e. multiple layers of clothing in warm weather)?
Yes No
Has the Veteran refused services or housing at least three times?
Yes No
Has the Veteran refused to be entered into the Coordinated Access/Chicago Ending Veteran Homelessness Initiative database due to paranoia?
Yes No
Does the Case Manager/Outreach worker believe the applicant to be a candidate for the Safe Haven housing model?
Yes No