Healthy Opportunities Referral Form for Providers

Trillium providers can begin receiving HOP Referrals on May 15th, 2024

This form may be used by Trillium contracted providers who are supporting Trillium members who are receiving Tailored Care Management, but are NOT contracted to do Pilot/HOP or a Trillium provider supporting a Trillium member via HFW or ACT.

Referrals for members who are believed to be eligible for the Healthy Opportunities Pilot may be assessed for the Pilot by Trillium. Please be able to answer the below questions with YES prior to submitting the referral form.

Does the member reside in a Pilot County?
Is the member receiving TCM/ACT/HFW?
Is the member experiencing a social risk factor in one or more of the following areas;
Housing
Food
Transportation
Toxic Stress/Interpersonal Safety

Before a referral is made, the TCM/HFW/ACT Provider will ensure:

The member understands they will need to complete a Pilot eligibility and service assessment to determine eligibility for Pilot Services - eligibility it NOT guaranteed.
The member understands that if found eligible, they must be willing to complete consents for NCARE360 & the Pilot in order to participate. This means the member is consenting to their information being entered into this database and their information is being shared with Human Service Organizations (HSOs)
Oher available resources have been explored (and documented in this form) prior to sending the referral to Trillium.
The member understands that this is a PILOT and availability of PILOT services are dependent on capacity, funding and other factors.

Referrer Name*

ie; Tailored Care Manager Name

Referral Contact E-mail*

TCM Provider Name*

Select

Member Name*

Please enter the Member's First Name THEN Last Name.

Member Date of Birth*

Member Record Number*

Member Insurance*

Select

County of Residence*

To be eligible for the Pilot, members must reside in one of the following counties.

Beaufort, Bertie, Chowan, Edgecombe, Halifax, Hertford, Martin,

Northampton, Pitt, Bladen, Brunswick, Columbus, New Hanover, Onslow, Pender

Select

Follow up with*

Select or enter value

Contact Name*

Contact Number*

Permission to Leave Voicemail*

Select or enter value

Contact Email

Contact's Relationship to Member*

Social Determinant of Health Referral Categories

Please select the relevant referral category(s) and then provide a brief description of the need(s). (Mark all that apply)

Area of Need*

Please select the domain(s) in which the member is experiencing a social risk factor. Please select ALL that apply.

Select or enter value

Please provide a description of EACH selected need above. Please include what has been tried previously and barriers that prevented this from working.

Ie; Member is experiencing food insecurity and has been connected to SNAP - However, SNAP does not provide adequate food supply that supports member's diet for pre-diabetes.

Need(s) Description*

Healthy Opportunities Category*

Please select ALL of the below categories that apply to this member. Please only select categories that have been verified. If you are unsure, please leave blank. Leaving blank will NOT exclude a member from being evaluated for the Healthy Opportunities Pilot.

Select

Age 0-3 Criteria*

Select

Age 4-20 Criteria*

Select

Age 21+ Criteria*

Select

Pregnancy Details*

Select

Chronic Conditions

Select

Please document any rationale/descriptive information as needed for the selected category of eligibility.*

i.e.; Member is diabetic, food insecure and has a prescribed diet - please see attached form with details.

Supporting Documents*

This may ALSO include SNAP verification, dietary instructions from a doctor and/or other supporting documents that would be of assistance while working with the member.

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