Quarterly telephone calls

The Effect of Reducing Falls on Acute and Long -Term Care Expenses

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Quarterly telephone calls

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APPENDIX C

IN-PERSON ASSESSMENT INSTRUMENT

(FOR USE AS BOTH INITIAL AND FINAL ASSESSMENT)

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Referral Number:

Participant Name:

Address:

Phone Number:

Independent Living

and

Mobility Program

In-Person Interview

Assessor

Print your name with credentials and the date that the interview was completed.

Name and credentials:

______________________________________________

Date of interview: __________________________________________________

Was more than one person in this household interviewed?

.......................................................................

No

Yes

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1.

Instructions

Please read this paragraph to the participant before beginning the interview.

My name is ______________, and I will be interviewing you and taking

your height, weight and blood pressure readings as part of the Independent

Living and Mobility Program.

The interview takes approximately one hour. I will be asking questions

about your health and daily activities and will perform a brief home safety

evaluation.

I will be asking you questions on a number of different topics. Some of these

questions may or may not be applicable to you; but it is important that we

ask all participants the same questions.

If this is the initial in-person assessment add:

The information from this interview will be sent to the home office where a

report will be created that highlights things you can do to improve your

safety and reduce the chance of falling in your home. This report will then

be sent to you. Along with the summary, a Health Promotion and

Independent Living and Mobility Tool kit will be sent to you that contains

1)

Health and Home Safety Handout,

2)

Wipe-Off Medication Management Planner,

3)

Exercise video,

4)

Exercise Progress Chart,

5)

Falls Journal in which you can record any falls or near falls that may occur and

6)

Pedometer.

Additionally, you will be receiving a quarterly follow-up phone call shortly

after this interview. In the interim, if you have any questions regarding the

Independent Living and Mobility Program, please contact XXXXXXXX at XXX-

XXX-XXXX.

If this is the final in-person assessment add:

This is the final interview that we will be conducting, thank you for

participating in this important national program over the past 2 years.

For all assessments finish the introduction with:

Do you have any questions regarding the interview before we begin?

Please document any questions the participant has.

_______________________________________________________

_______________________________________________________

_______________________________________________________

Enter the time the

interview begins

(i.e. 2:53 PM).

Exact time:

:

am/pm

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2.

General Questions

A.

Do you have any visual deficits? (If “Yes,” explain below) .............................................................................................................

No

Yes

B.

Do you have any hearing deficits? (If “Yes,” explain below)...........................................................................................................

No

Yes

Condition

Date of

Diagnosis

(month/year)

Dr. Name

Treatment

Current Status

C.

Are you having any difficulty understanding me? (If “Yes,” explain below) ....................................................................................

No

Yes

Reason for difficulty:

What can be done to compensate for this problem?

A.

Assessor:

compensate as best you can and then ask:

Now can you understand me? (If “No,” terminate interview).......................................................

No

Yes

3.

Hospital/Emergency Visits and Surgery

A.

Since your recent phone interview have you had any Hospital Admissions, Emergency Room visits or Surgery?........................

No

Yes

If Yes, indicate number of times: _________

Reason for Hospital Admission/

Emergency Room visit/ Surgery

Date

(month/year)

Type of Surgery &/or

Treatment received

Current Status

4.

Primary Care Physician

A.

Do you have a primary care physician? .......................................................................................................................................

No

Yes

Physician’s name: ____________________________Phone number:_____________________

City: ______________________ State __________Street address:

____________________

Specialty: ___________________

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5.

Falls History

A.

Since your recent phone interview have you had one or more episodes of fainting, falling or dropping

to the ground, passing out or have you lost your balance, slipped or tripped over something that

resulted in falling or dropping to the ground?....................................................................................................................

No

Yes

If Yes, How many times did this happen? ______________________________________

Regarding your most recent fall, what time of day did it happen? .......................................................

Day

Eve

Morn/Day

5:01AM-9:00AM

9:01AM-12:00PM

12:01PM-4:00PM

Eve/Noc

5:01PM-7:00PM

7:01PM-10:00AM

10:01AM-5:00AM

Did you get hurt or injure yourself?......................................................................................................

No

Yes

Did you require Medical Attention? ......................................................................................................

No

Yes

Emergency Room Visit

Hospital Admission

Doctor Visit

What were you doing when you fell? ______________________________________

_________________________________________________________

Were you at home when you fell? ........................................................................................................

No

Yes

If Yes, Where?

Bathroom

Kitchen

Entryway

Stairs

Other:

If No, Where?

Store/Business

Parking Lot/Street

Relative/Friend House

Dr. Office

Walkway/Pathway

Other

_____________

What was the cause of your fall?

Tripped

Slipped

Dizziness

Seizure

Loss of Balance

Fainted/Blacked out

Other:

Were any of the following conditions present when you fell? (read all)

Ground conditions

Wet Ground .........................................

No

Yes

Icy/snowy Ground ...............................

No

Yes

Uneven Ground....................................

No

Yes

Stepping up onto/down from a Curb ....

No

Yes

Climbing up/going down stairs ............

No

Yes

Object in walkway/path.......................

No

Yes

Behaviors For each Yes, answer additional question

Additional Question

Wearing shoes that did not fit properly ..

No

Yes

Have you changed this behavior?..................

No

Yes

Wearing clothes that did not fit properly.

No

Yes

Have you changed this behavior?..................

No

Yes

Not using necessary visual aid/glasses...

No

Yes

Have you changed this behavior?..................

No

Yes

Not using necessary equipment ..............

No

Yes

Have you changed this behavior?..................

No

Yes

(cane, walker, shower seat, grab bars)

No

Yes

B.

Have you been anxious or worried or afraid you might fall?...........................................................................................

No

Yes

C.

Do you ever limit your activities, for example, what you do or where you go because you are afraid of

falling?..........................................................................................................................................................................................

No

Yes

If Yes, Which activities and why? ____________________________________________

________________________________________________________________

How often?

All of the time

Some of the time

Rarely

Doesn’t know

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6.

Medications

A.

Please tell me the names and dosages of all the medications you currently take including non-prescription

medications, eye drops and inhalers. (Assessor - Please obtain details for all medications)

Medication Name

Dosage

Frequency

If PRN,

indicate how

often used

Reason for taking

Do you take

this as

prescribed by

your doctor?

If NO, Why Not?

Too Expensive,

Side Effects;

“I don’t need them”,

”They don’t work”,

Ran out of Rx,

Forgets, Other:

1

Yes

No

2

Yes

No

3

Yes

No

4

Yes

No

5

Yes

No

6

Yes

No

7

Yes

No

8

Yes

No

9

Yes

No

10

Yes

No

11

Yes

No

12

Yes

No

13

Yes

No

14

Yes

No

15

Yes

No

16

Yes

No

17

Yes

No

18

Yes

No

19

Yes

No

20

Yes

No

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7.

Medical Conditions and Symptoms

A.

Do you have a history of any of the following conditions? (if any answer is “Yes,” explain below)

Irregular Heart Beat/A-fib/Arrhythmia..............

No

Yes

Sciatica, Back pain or swelling........................

No

Yes

High Blood Pressure ..........................................

No

Yes

Foot Disorders................................................

No

Yes

Low Blood Pressure ...........................................

No

Yes

Ankle, Knee or Hip replacement.....................

No

Yes

Congestive Heart Failure ...................................

No

Yes

Ankle, Knee or Hip pain, swelling or redness.

No

Yes

Heart Attack ......................................................

No

Yes

Amputation of Leg, Foot or Toe ......................

No

Yes

Any other heart problem(s)................................

No

Yes

Cancer, Leukemia, Lymphoma........................

No

Yes

Vitamin B12 Deficiency or Anemia .....................

No

Yes

Diabetes.........................................................

No

Yes

Other blood disorder?........................................

No

Yes

Numbness (where?)..................................

No

Yes

Circulatory Problems .........................................

No

Yes

Weakness (where?) ..................................

No

Yes

Stroke, TIA or “Mini-Stroke” ..............................

No

Yes

Fatigue ...........................................................

No

Yes

Paralysis (where?) .......................................

No

Yes

Tremors (where?) .....................................

No

Yes

Peripheral Neuropathy ......................................

No

Yes

Seizures, convulsions (date of last).........

No

Yes

Multiple Sclerosis...............................................

No

Yes

Neurological Problems ...................................

No

Yes

Parkinson’s Disease ..........................................

No

Yes

Unsteadiness/Imbalance ................................

No

Yes

Alzheimer’s Disease/Dementia..........................

No

Yes

Psychiatric Disorders .....................................

No

Yes

Shortness of breath/Difficulty Breathing............

No

Yes

Depression .....................................................

No

Yes

Asthma, Emphysema, COPD, Chronic Cough.......

No

Yes

Anxiety ..........................................................

No

Yes

Arthritis (Type? Location?) ....................

No

Yes

Alcoholism/Drug Addiction .............................

No

Yes

Osteoporosis .....................................................

No

Yes

Dizziness/Vertigo ...........................................

No

Yes

Bone Fractures (where? why?)................

No

Yes

Insomnia/difficulty sleeping ..........................

No

Yes

B.

If any condition

is answered “Yes,” gather details in the grid below

Condition

Date of

Diagnosis/

1

st

Symptom

Date of most

recent

Symptom

Is Condition

treated by a

doctor?

Is Condition

Controlled/

Stable?

Treatment

1

No

Yes

No

Yes

2

No

Yes

No

Yes

3

No

Yes

No

Yes

4

No

Yes

No

Yes

5

No

Yes

No

Yes

6

No

Yes

No

Yes

7

No

Yes

No

Yes

8

No

Yes

No

Yes

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9

No

Yes

No

Yes

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8.

Physical Measurements

Some falls occur when people stand up from a lying position because their blood pressure drops. Therefore, I

would like to take your blood pressure from two positions – one when you are lying down, then one after you

stand up from a lying position. Please lie down on a couch for the first blood pressure and pulse.

A. Supine BP: _____ / _____

Exact Time: ____: _____ (wait no more than 1 minute before taking standing BP)

& Heart rate:_____

What does your blood pressure usually run? _____ / _____ or

Unknown

Now please stand up and I will take your blood pressure and pulse again.

B. Standing BP: _____ / _____

Exact Time: ____: _____

& Heart rate:_____

C. Height: ____ft._____ in.

Have you had any loss of height? .............................................................................

No

Yes

How much?

Reason:

D. Weight: _________ lbs.

9.

Activities of Daily Living & Physical Performance Measurements

The next questions concern your

current ability to perform daily activities. I will first ask if you have any

difficulty doing the activity, then if you receive any assistance or use any equipment and then I will ask you to

demonstrate the motions that are required to complete the activities. I will also be asking to do a safety

evaluation in your kitchen, bedroom, the bathroom that you use most often and the rooms in which you spend

most of your time.

Assessor: As you view each room, look to see that flooring is securely attached (including

area rugs), walkways are well lit and clear of obstructions, thresholds are only ½ inch high, furniture is sturdy

and note any nightlights that are used regularly.

B.

Transferring:

1.

Do have difficulty when transferring in or out of a bed or chair without assistance from another person? .............................

No

Yes

1.

_________________________________________________________________

If Yes,

Describe

why completion of this activity is difficult for you:

_________________________________________

2.

____________________________________________________________

3.

____________________________________________________________

4.

____________________________________________________________

2.

Does anyone help you transfer in and out of a bed or chair?...................................................................................................

No

Yes

3.

Do you use equipment when transferring from a bed or chair? ...............................................................................................

No

Yes

5.

_________________________________________________________________

If Yes identify

type:

hoyer lift

chair lift

walker

cane

other___________

4.

Please stand up then sit back down for me.

Assessor: Did the participant have any difficulty completing this task?

........................................................

No

Yes

6.

If Yes, choose one and explain:

Difficulty noted

Not completed,

safety issue

7.

____________________________________________________________

8.

____________________________________________________________

9.

____________________________________________________________

10.

___________________________________________________________

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5.

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

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C.

Mobility Outside:

1.

Do have difficulty when walking outside your home (within walking distance) including negotiating uneven surfaces (curbs,

ramps, sidewalks, uneven ground etc…) without assistance from another person? ..............................................................

No

Yes

11.

___________________________________________________________

If Yes,

Describe

why completion of this activity is difficult for you:

_____________________________________

12.

___________________________________________________________

13.

___________________________________________________________

14.

___________________________________________________________

2.

Does anyone help you when you walk outside your home?.....................................................................................................

No

Yes

3.

Do you require equipment when walking outside your home? ................................................................................................

No

Yes

If yes, identify type:

scooter

wheelchair

walker

cane

other_________

4.

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

D.

Chair stands

1.Baseline Chair Stand

These next exercises measure the strength in your legs. Please sit in a chair that is at a comfortable height.

Do you think it would be safe for you to try to stand up from a chair without using your arms? .........................................

No

Yes

If Yes:

Demonstrate chair stand for participant as you explain and record results below

First fold your arms across your chest and sit so that your feet are on the floor, then try to stand up,

keeping your arms folded across your chest.

Gets up easily on first try....................................................

(continue with #2 below)

Gets up on first try but has difficulty...................................

(continue with #2 below)

Requires more than one attempt .........................................

(continue with #2 below)

Can rise but not without using arms.....................................

(skip to next page)

Cannot rise without assistance from another person ...........

(skip to next page)

Refused to participate ..........................................................

(indicate reason and skip to next page)

Fear of falling

Physically unable

Other:

If No:

Record reason and skip to next page

Cannot rise without assistance from another person ...........

(skip to next page)

Refused to participate ..........................................................

(indicate reason and skip to next page)

Fear of falling

Physically unable

Other:

2.

Timed Chair Stands (do not complete if participant indicates it is unsafe to stand without using arms)

C.

Assessor: use a STOP

WATCH or WATCH WITH A SECOND HAND for this section.

OK, now I am going to ask you to stand up a few more times. Please keep your arms folded across your chest

and stand up straight as many times as you can until I tell you to stop. After standing up each time, sit down

and then stand up again. Keep your arms folded across your chest. I will be timing you for 30 seconds. OK,

are you ready? Stand.

Assessor:

Start timing

and

Count out loud how many times

the

participant rises from the chair during the 30 seconds. Record results below. Stop

timing if there is a safety concern.

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Timed for 30 seconds – Indicate the number of times participant stood from chair during 30 seconds:

_______chair stands

Time stopped due to safety concern at:

seconds. Number of chair stands during that time:

chair stands

Time stopped due to participant’s inability to complete any chair stands with arms folded on chest.

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E.

Mobility Inside & timed get up and go:

1.

Do you have difficulty when walking from one room to another inside your home without assistance from another

person?.................................................................................................................................................................................

No

Yes

15.

___________________________________________________________

If Yes,

Describe

why completion of this activity is difficult for you:

_____________________________________

16.

___________________________________________________________

17.

___________________________________________________________

2.

Does anyone help you walk from one room to another inside your home? .............................................................................

No

Yes

3.

Do you require equipment when performing this activity? ......................................................................................................

No

Yes

If yes, identify type:

stair lift

wheelchair

walker

cane

other_________

4.

Do you think it would be safe for you to stand up from a chair walk 8 feet and back then sit back down? ..............................

No

Yes

D.

If Yes

: Use

Measuring Tape to measure out 8 feet. Stand 8 feet from participant and say:

OK, I am going to time how long it takes you to stand up, walk to here

(8 feet from where participant is

seated),

turn around, walk back and sit down on that seat again. Are you ready?

OK, Go.

(START TIMING and Describe below)

Time taken for participant to rise from chair, walk 8 feet, turn, walk back and sit down again: _______seconds

Posture

:

(e.g. : erect, kyphotic)

___________________________________________

Balance:

(e.g. : steady, imbalanced)

________________________________________

Pace:

(e.g. : fast, medium, slow)

___________________________________________

Stride length:

(e.g. : short, medium, long)

_____________________________________

Step height

:

(e.g. : shuffle, exaggerated, natural)

________________________________

Gait:

(e.g. : smooth, choppy , stiff)

_________________________________________

Arm movement

:

(e.g. : pendulum swing, stiff, bent elbows)

__________________________

Ability to turn

:

(e.g. natural, small steps, unbalanced)

____________________________

Physical Abnormalities/Deformities/Equipment: __________________________________

If No, Why would it not be safe?

Assessor: Did the participant have any difficulty completing this task?...........................................................

No

Yes

18.

If Yes, choose one and explain:

Difficulty noted

Not completed,

safety issue

19.

___________________________________________________________

20.

___________________________________________________________

21.

___________________________________________________________

5.

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

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F.

Four-test balance scale

E.

DO NOT DO this test if participant cannot stand without the assistance of a

person/assistive device or if s/he feels it is unsafe. Use a STOP WATCH or a WATCH WITH A

SECOND HAND for this section. No practices are allowed for these exercises and they should be

carried out in bare feet or stocking feet. You may help the person in to each position, but the person

must hold the position unaided. Each position must be held for 10 seconds before progressing to

the next position.

F.

Stop timing if:

(1) the person moves

their feet from the proper position,

G.

(2) you provide contact

to prevent a fall or

H.

(3) the person touches

the wall or other support with their hand.

I.

Many falls are caused by imbalance, so next I will check your balance. For this exercise, please take off

your shoes. I will ask you to stand in 4 different positions for about 10 seconds each.

1.

Feet Together Stand

First I would like you to try to stand with your feet together, side-by-side, for about 10 seconds

(show picture)

. You may use your arms, bend your knees or move your body to maintain your

balance, but try not to move your feet. Try to hold this position until I tell you to stop.

OK, Start.

(Time for 10 seconds)

Ok, Stop.

(Record result below)

Held position successfully for 10 seconds

Held position successfully, but not for 10 seconds

Unable to hold position/did not do (indicate reason and skip to next page)

Fear of falling

Physically unable

Other: _________________

2.

Semi-tandem stand

Next, I want you to try to stand with the side of the heel of one foot touching the big toe of the other

foot for about 10 seconds

(show picture)

. You may put either foot in front, whichever is more

comfortable for you. You may use your arms, bend your knees or move your body to maintain your

balance, but try not to move your feet. Try to hold this position until I tell you to stop.

OK, Start.

(Time for 10 seconds)

Ok, Stop.

(Record result below)

Held position successfully for 10 seconds

Held position successfully, but not for 10 seconds

Unable to hold position/did not do (indicate reason and skip to next page)

Fear of falling

Physically unable

Other: _________________

3.

Tandem stand

Now, I want you to try to stand with the heel of one foot in front of and touching the toes of the other

foot for about 10 seconds

(show picture)

. You may put either foot in front, whichever is more

comfortable for you. You may use your arms, bend your knees or move your body to maintain your

balance, but try not to move your feet. Try to hold this position until I tell you to stop.

OK, Start.

(Time for 10 seconds)

Ok, Stop.

(Record result below)

Held position successfully for 10 seconds

Held position successfully, but not for 10 seconds

Unable to hold position/did not do (indicate reason and skip to next page)

Fear of falling

Physically unable

Other: _________________

4.

One leg stand

Now, I want you to try to stand on one foot (only if you feel it is safe!), raising the other foot off of the

ground for about 10 seconds

(show picture)

. You may use whichever foot is more comfortable for

you. You may use your arms, bend your knees or move your body to maintain your balance, but try not

to put the other foot down. Try to hold this position until I tell you to stop.

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OK, Start.

(Time for 10 seconds)

Ok, Stop.

(Record result below)

Held position successfully for 10 seconds

Held position successfully, but not for 10 seconds

Unable to hold position/did not do (indicate reason and skip to next page)

Fear of falling

Physically unable

Other: _________________

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G.

Eating

(Note: Eating does not include meal preparation, cooking, cutting food, pouring liquids or buttering bread):

1.

Do you have difficulty eating without assistance from another person?..................................................................................

No

Yes

22.

___________________________________________________________

If Yes,

Describe

why completion of this activity is difficult for you:

_____________________________________

23.

___________________________________________________________

24.

___________________________________________________________

25.

___________________________________________________________

2.

Does anyone help you eat?......................................................................................................................................................

No

Yes

3.

Do you require equipment when eating? .................................................................................................................................

No

Yes

26.

_________________________________________________________________

If Yes identify

type:

Feeding tube

TPN

other:__________

4.

Please demonstrate how you grasp a cup and then a fork or spoon.

(Use pen if fork/spoon not available)

Assessor: Did the participant have any difficulty completing this task?

........................................................

No

Yes

27.

____________________________________________________________

If Yes, choose

one and explain:

Difficulty noted

Not completed, safety issue ________________________

28.

____________________________________________________________

29.

____________________________________________________________

5.

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

H.

Kitchen safety evaluation

Let’s go into the kitchen and I will evaluate the lighting, counter height and flooring.

1.

Is lighting adequate (light bulbs greater than 60 watts) in this room?

..............................................................

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

2.

Are counters and shelves at an appropriate height such that items can be easily reached?

.......................

No

Yes

If No: Explain: ____________________________________________________________

Is a sturdy, non-skid step stool used to reach items outside participant’s reach?

.....

No

Yes

I.

Stairway Safety Evaluation

Next I would like to see any stairs that you use.

1.

Are the stairs used to enter/exit well lit with sturdy railings on both sides?

..............................

None

No

Yes

If No: Explain:

________________________________________________

2.

Are the stairs inside the home well lit with sturdy railings on both sides?

.................................

None

No

Yes

If No: Explain:

________________________________________________

J.

Bedroom safety evaluation

Next I will ask you about dressing, let’s go into the bedroom and I will evaluate the lighting, mattress

safety, flooring and pathway to the bathroom.

1.

Is the mattress firm and sag resistant and at a height that enables easy transfers?

.......................................

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

2.

Is there a clear path from where participant sleeps to the bathroom for easy navigation in the dark?

.....

No

Yes

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If No: Explain: ____________________________________________________________

________________________________________________________________________

3.

Are nightlights used so that the pathway to the bathroom is visible at night?

.................................................

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

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K.

Dressing:

1.

Do you have difficulty when dressing/undressing including getting your clothes from closets/drawers, putting them on and

taking them off and doing buttons, hooks and zippers without assistance from another person? ...........................................

No

Yes

30.

___________________________________________________________

If Yes,

Describe

why completion of this activity is difficult for the participant:

_______________________________

31.

___________________________________________________________

32.

___________________________________________________________

33.

___________________________________________________________

2.

Does anyone help you dress or undress? ................................................................................................................................

No

Yes

3.

Do you require equipment when dressing or undressing? .......................................................................................................

No

Yes

34.

_________________________________________________________________

If Yes identify

type: ___________

4.

Please show me the movements you use to get your clothes, put on a shirt, pants/skirt and shoes.

Assessor: Did the participant have any difficulty completing this task?

........................................................

No

Yes

35.

If Yes, choose one and explain:

Difficulty noted

Not completed,

safety issue

36.

___________________________________________________________

37.

___________________________________________________________

38.

___________________________________________________________

5.

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

L.

Bathroom safety evaluation:

Next I will ask you about bathing and toileting, let’s go into the bathroom and I will evaluate the lighting

and the flooring in the bathing area and toilet are as well as check if there are any grab bars.

1.

Is lighting adequate (light bulbs greater than 60 watts) in the tub, toilet and shower areas?

.....................

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

2.

Are grab bars securely fastened for use while bathing in the bathing area?

...................................

None

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

3.

Are grab bars/toilet safety frame securely fastened for use with getting on and off toilet?

..........

None

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

4.

Is there a bath mat or non-skid flooring in tub/shower?

.......................................................................................

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

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5.

Are nightlights used so the bathroom is visible at night?

......................................................................................

No

Yes

If No: Explain: ____________________________________________________________

________________________________________________________________________

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Many falls that occur in the home occur in the bathroom while people are transferring on and off the

toilet and getting in and out of the shower or tub. Since these two actions are the most common cause

of fall, I am going to ask you to demonstrate how you do these activities for me.

M.

Bathing:

A. How do you usually bathe?

Sponge Bath

Whirlpool/Tub

Shower in

Tub

Shower in

Stall/Walk-in Shower

1.

Do you have difficulty when bathing including getting to and from and in and out of the bathing area, washing and

drying all parts of your body without assistance from another person?...............................................................................

No

Yes

39.

___________________________________________________________

If Yes,

Describe

why completion of this activity is difficult for you:

_____________________________________

40.

___________________________________________________________

41.

___________________________________________________________

42.

___________________________________________________________

2.

Does anyone help you bathe?...............................................................................................................................................

No

Yes

3.

Do you require equipment when bathing? ............................................................................................................................

No

Yes

43.

__________________________________________________________________

If Yes identify

type:

bath bench/seat

hand held shower

grab bars

other_____

4.

Please show me how you get in and out of your bathing area and show me how you can wash your head, back and feet.

Assessor: Did the participant have any difficulty completing this task?

........................................................

No

Yes

44.

____________________________________________________________

If Yes, choose

one and explain:

Difficulty noted

Not completed, safety issue ________________________

45.

____________________________________________________________

46.

____________________________________________________________

5.

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

N.

TOILETING:

1.

Do you have difficulty when toileting including getting to and from and on and off the toilet, cleaning yourself after

elimination and adjusting your clothing without assistance from another person?...............................................................

No

Yes

47.

___________________________________________________________

If Yes,

Describe

why completion of this activity is difficult for the participant:

_______________________________

48.

___________________________________________________________

49.

___________________________________________________________

50.

___________________________________________________________

2.

Does anyone help you toilet at all?.......................................................................................................................................

No

Yes

3.

Do you require equipment when performing this activity? ...................................................................................................

No

Yes

51.

________________________________________________________________

If Yes identify

type:

bedpan

urinal

commode

raised toilet seat

52.

_________________________________________________________________

walker

cane

wheelchair

toilet safety frame

other___________

4.

Please show me how you get on and off of your toilet.

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Assessor: Did the participant have any difficulty completing this task?

........................................................

No

Yes

53.

____________________________________________________________

If Yes, choose

one and explain:

Difficulty noted

Not completed, safety issue ________________________

54.

____________________________________________________________

55.

____________________________________________________________

5.

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

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O.

BLADDER CONTINENCE:

1.

Do you ever experience any loss of bladder control? ...........................................................................................................

No

Yes

2.

Do you use a urostomy or a catheter? ..................................................................................................................................

No

Yes

56.

....................................................................................................................................

I

f No to both questions, skip to Bowel Continence question.

57.

....................................................................................................................................

I

f Yes to either question:

Do have difficulty when washing yourself, disposing of soiled items, changing or adjusting your

clothing or caring for the medical device without assistance from another person? .........................

No

Yes

58.

__________________________________________________

If Yes,

Describe why completion

of this activity is difficult you:

________________________________________

59.

__________________________________________________

_________

60.

__________________________________________________

_________

61.

__________________________________________________

_________

Does anyone help you when you are incontinent? ............................................................................

No

Yes

Do you require equipment when because of your bladder incontinence?..........................................

No

Yes

62.

_________________________________________________________________

If Yes identify

type:

pads

briefs

urostomy

catheter

other__________

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

P.

BOWEL CONTINENCE:

1.

Do you ever experience any loss of bowel control?..............................................................................................................

No

Yes

2.

Do you use a colostomy or ileostomy?..................................................................................................................................

No

Yes

63.

....................................................................................................................................

I

f No to both questions, skip to next page.

64.

........................................................................................................................

I

f “Yes” to either question

Do have difficulty when washing yourself, disposing of soiled items, changing or

adjusting your clothing or caring for the medical device without assistance from another person? ...............................

No

Yes

65.

___________________________________________________________

If Yes,

Describe

why completion of this activity is difficult you:________________________________________

66.

___________________________________________________________

67.

___________________________________________________________

68.

___________________________________________________________

Does anyone help you when you are incontinent? ............................................................................

No

Yes

Do you require equipment when because of your bladder incontinence?..........................................

No

Yes

69.

_________________________________________________________________

If Yes identify

type:

pads

briefs

colostomy

ileostomy

other__________

Based on the information above and using your clinical judgment, choose the level of assistance from

another person most often required for the insured to complete this activity: (Choose only one)

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No physical assistance from another person required

Stand-by assistance from another person required – within arm’s reach for safety

Hands-on assistance from another person required – physical assist

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10.

Current Care

Q.

Do you receive personal care or assistance from any paid caregivers (including Medicare services)?.............................................

No

Yes

J.

Assessor: Below

please document any and all paid services provided to the participant.

Service Provider

(e.g. RN, CNA)

Service Provided

(e.g. skilled care, ADLs,

supervision, etc.)

Frequency per Week and Hours

per Day

(e.g., 2-3 hrs / day 7 days / wk)

Projected Duration

(e.g., Long term, 3

weeks, 3-6 weeks

)

Start Date of

Service

Hourly

Rate/

monthly fee

K.

R.

Do you receive personal care or assistance from any unpaid caregivers (including family members/friends)?...............................

No

Yes

L.

Assessor: Below

please document any and all services provided to the participant.

Unpaid Caregiver Name

and relationship

Service Provided

(check all that apply)

Frequency per Week and

Hours per Day

(e.g., 2-3 hrs/day 7 days/wk)

Projected Duration

(e.g., Long term, 3 weeks,

3-6 weeks

)

Start Date of

assistance

Does this person live

with the participant?

No

Yes

Bathing

Dressing

Transfers

Eating

Toileting

Continence

IADLs

Companionship

Supervision

Med Administration

Other____________

Does this person live

with the participant?

No

Yes

Bathing

Dressing

Transfers

Eating

Toileting

Continence

IADLs

Companionship

Supervision

Med Administration

Other____________

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Does this person live

with the participant?

No

Yes

Bathing

Dressing

Transfers

Eating

Toileting

Continence

IADLs

Companionship

Supervision

Med Administration

Other____________

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11.

Summary of Home Safety Evaluation

M.

Assessor: Take one last walk

through any rooms that you viewed and answer the following questions about the areas where the

participant spends most of his/her time. Please supply details for each “No” answer.

1.

Is flooring non-skid and firmly attached to floor?

..................................................................................................

No

Yes

If No: in which rooms:

Bathroom

Bedroom

Kitchen

Other:__________

Explain:__________________________________________________________________

________________________________________________________________________

2.

Are walkways are well lit, visible and free of obstruction and clutter?

.............................................................

No

Yes

If No: in which rooms:

Bathroom

Bedroom

Kitchen

Other:__________

Explain:__________________________________________________________________

________________________________________________________________________

3.

Are thresholds at a height no greater than ½ inch?

...............................................................................................

No

Yes

If No: in which rooms:

Bathroom

Bedroom

Kitchen

Other:__________

Explain:__________________________________________________________________

________________________________________________________________________

4.

Are scatter rugs (throw rugs) securely fastened to the floor?

..............................................................

None

No

Yes

If No: in which rooms:

Bathroom

Bedroom

Kitchen

Other:__________

Explain:__________________________________________________________________

________________________________________________________________________

5.

Are the electrical cords cleared from pathways?

....................................................................................................

No

Yes

If No: in which rooms:

Bathroom

Bedroom

Kitchen

Other:__________

Explain:__________________________________________________________________

________________________________________________________________________

6.

Are seats and chairs safe for transfers with sturdy footing and secure armrests?

.........................................

No

Yes

If No: in which rooms:

Bathroom

Bedroom

Kitchen

Other:__________

Explain:__________________________________________________________________

________________________________________________________________________

7.

Are counters/furniture secure enough to provide support if leaned upon for mobility assistance?

.........

No

Yes

If No: in which rooms:

Bathroom

Bedroom

Kitchen

Other:__________

Explain:__________________________________________________________________

________________________________________________________________________

8.

Other than was noted in the previous few pages, did the participant’s home appear to be hazard-free?

.

No

Yes

If No: Explain other safety hazards noted:

______________________________________

________________________________________________________________________

12.

Wrap up

If this is the initial in-person assessment end with:

Thank you for your participation in the Independent Living and Mobility Prevention Program. A summary of this interview

will be sent to you along with recommendations of how to maintain your independence over time and keep your home

safer. Also we will be sending the Health Promotion and Fall Prevention Tool kit mentioned at the beginning of the

interview. Additionally, a clinician will be calling you every 3 months or so to gather information from your Exercise

Progress Chart and Falls Journal which are part of the Tool kit. As part of the program, you will be asked to document in

your Exercise Progress Chart an on a weekly basis and in the Falls Journal every time you ever experience a fall or a near

fall of some kind. Thank you again for your participation!

Enter the time the

interview ends

(i.e. 2:53 PM).

Exact time:

:

am/pm

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If this is the Final in-person assessment end with:

Thank you for your participation in the Independent Living and Mobility Program. This ends the 2 year study,

we really appreciate the time you have invested in this important national program.

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13.

Clinical Summary

N.

Assessor: Complete

the Clinical Summary after you have left the Participant’s home. Please be sure to

provide an answer for each question

A.

Was there any indication that the participant is unsafe to be left alone?.................................................................................

No

Yes

If Yes, explain __________________________________________________________

___________________________________________________________________

___________________________________________________________________

B.

Was there any indication that the participant is not taking reasonable care of his/her home environment in terms of

cleanliness, neatness and minimizing clutter? ........................................................................................................................

No

Yes

If Yes, explain __________________________________________________________

___________________________________________________________________

___________________________________________________________________

C.

Was there any indication that the participant is not taking reasonable care of themselves in terms of appearance,

hygiene, and grooming? .........................................................................................................................................................

No

Yes

If Yes, explain __________________________________________________________

___________________________________________________________________

___________________________________________________________________

D.

Was anyone other than the participant present during any part of the interview? ..................................................................

No

Yes

Who:

Relationship to participant:

E.

Did anyone other than the participant answer any of the interview questions? ......................................................................

No

Yes

If Yes, explain __________________________________________________________

___________________________________________________________________

___________________________________________________________________

F.

Does the participant appear to be in immediate danger due to an unsafe home environment?...............................................

No

Yes

If Yes, explain __________________________________________________________

___________________________________________________________________

___________________________________________________________________

G.

Did you observe any non-reported safety issues (including skin breakdown, bruises, malnourishment etc…)? ....................

No

Yes

If Yes, explain __________________________________________________________

___________________________________________________________________

___________________________________________________________________

H.

Are there any other concerns or comments that you feel should be documented or explained?..............................................

No

Yes

If Yes, explain __________________________________________________________

___________________________________________________________________

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___________________________________________________________________

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14.

Field Based Observations

O.

Please use the

information you gathered during the interview to identify unmet needs that should be

addressed in the summary that will be sent to the participant.

1.

Do you feel the insured has the appropriate equipment in his/her home? ...............................................................................

Yes

No

P.

Check all

equipment/safety devices that the insured does not have, but would benefit from, to

remain safely in his/ her present location: For each piece of equipment noted, indicate

why it is needed below:

Straight Cane

Hospital Bed

Commode

Multi-pronged Cane

Tub rail (tub)

Raised Toilet Seat

Walker

Bath/shower Stool

Toilet Safety Frame

1

Wheelchair

Shower bench with back

Medical Alert System

Electric Scooter

Hand Held Shower

2

Stair Lift

Electric Recliner

Grab Bars in shower/tub

Other: ________________

Type of Equipment

Reason recommended

2.

Do you feel the insured has the appropriate level, intensity and duration of services? ..........................................................

Yes

No

Q.

If No, complete

the table below. In the table below, check the type of care you would recommend for

this insured and provide information on frequency and duration.

Recommended Service

Recommended Frequency

Recommended Duration

Home Health Aide/Personal Care Attendant

____hrs/day ____d/wk

Homemaker/Companion

____hrs/day ____d/wk

Physical/Occupational/Speech Therapy

____hrs/day ____d/wk

Skilled Nurse

____hrs/day ____d/wk

Medical Social Worker

____hrs/day ____d/wk

Meals on Wheels/Nutritional Services

____meals/wk

Pharmaceutical Care

Transportation

Other_____________________

Other_____________________

Why are these services being recommended?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

1

Minimum requirement: 3 inches between toilet and sink/tub and no shelves above toilet with legs going to floor

2

Due to liability, typically Hand Held Showers will not be installed by the Medical Equipment Vendors

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~ PLEASE FAX IMMEDIATELY TO ----------------- WHEN COMPLETED! THANK YOU ~

Assessor signature:

Date of interview:

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File TitleMicrosoft Word - Appendix C.doc
Authorjmiller
File Modified2006-02-01
File Created2006-02-01

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