APPENDIX A

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APPENDIX B


TELEPHONIC RISK ASSESSMENT INSTRUMENT
(FOR USE AS BOTH INITIAL AND FINAL ASSESSMENT)

Form Approved
   OMB No. 0990-0308
   Exp. Date XX/XX/20XX




Referral Number:



Participant Name:	
Address: 	
Phone Number: 		


Independent Living 
and
Mobility Program
Phone Screening Assessment

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

Name and credentials:	

Date of interview:	
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0308 . The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,   Attention: PRA Reports Clearance Officer


    • Introduction
INITIAL CONTACT- Talking to insured
Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), your long-term care insurance company.  A few weeks ago, you agreed to participate in a national Program about Independent Living and Mobility that your LTC insurance company is participating in.  First, we want to thank you for your willingness to contribute to helping us understand such an important issue.  As part of the Program, we need to ask you some questions related to your general health history.  It will take about 20 minutes.  Do you have time to do that now or would you like to schedule a time that is more convenient for you?

INITIAL CONTACT - Talking to proxy
Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), (the insured’s name)’s long-term care insurance company.  A few weeks ago, you agreed to participate in a national Program about Independent Living and Mobility that their LTC insurance company is participating in.  First, we want to thank you for your willingness to contribute to helping us understand such an important issue.  As part of the Program, we need to ask you some questions related to (name of insured)’s general health history.  It will take about 20 minutes.  Do you have time to do that now or would you like to schedule a time that is more convenient for you?

FINAL CONTACT - Talking to insured
Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), your long-term care insurance company.  You have been participating in a national Program about Independent Living and Mobility for the past 24 months.  As the last telephone contact, we need to ask you the questions that we asked you at the very beginning of the Program.  It will take about 20 minutes.  Do you have time to do that now or would you like to schedule a time that is more convenient for you?

FINAL CONTACT - Talking to proxy
Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), (the insured’s name)’s  long-term care insurance company.  (the insured’s name) has been participating in a national Program about Independent Living and Mobility for the past 24 months.  As the last telephone contact, we need to ask you the questions that we asked at the very beginning of the Program.  It will take about 20 minutes.  Do you have time to do that now or would you like to schedule a time that is more convenient?
    • General Questions  
    1. Are you having any difficulty understanding me? (If “Yes,” explain how you compensated below)	No	Yes
	Compensation:	

    2. With whom do you live?	Alone	Spouse	Child(ren)	Grandchild(ren)	Parent
			Sibling	Other (name/relationship:	)______________________
    3. Do you live in a private residence (Free standing home or apartment/condominium)? 	No	Yes
If Yes, Is this part of an: Assisted Living Facility, Retirement Community or Elderly Housing?	No	Yes
If Yes, indicate which:   Assisted Living Facility     Retirement Community      Elderly Housing 
If No, Do you live in:   Assisted Living Facility     Retirement Community      Nursing Home
		  Other, type:	
    4. At the present time would you say your health is:	Excellent	Good	Fair	Poor     

    • Healthcare Use
    5. Do you have a primary care doctor or other physician you see regularly or when you have a medical problem?	No	Yes
    6. How often do you usually see a doctor?   Monthly   ~3 Mo   ~6 Mo   Yearly   < Yearly   Rarely
    7. In the past 2 years, have you had any surgery?	No	Yes
If Yes, indicate number of times:   _________
    8. In the past 2 years, have you had any emergency room visits?	No	Yes
If Yes, indicate number of times:   _________
    9. In the past 2 years, have you had any hospital admissions?	No	Yes
If Yes, indicate number of times:   _________
    10. Do you receive personal care or assistance from any paid or unpaid caregivers?	No	Yes
If Yes, Identify:     Paid Caregiver(s)     Unpaid Caregiver(s)     Both Paid and Unpaid Caregiver(s)
Approximately how much money do you spend per month on these paid caregivers?
none        less than $100        $100-$250	$251-$500	$501-$1000       $1001 or more
    • Medical Conditions and Symptoms
    11. In the past week or so, have you felt any…
    a. Lower body muscle weakness or generalized fatigue?	
No
Yes
    b. Pain in your back that affects your mobility or daily activities?	
No
Yes
    c. Loss of balance or unsteadiness when you walk or get up from a chair or bed?	
No
Yes
    d. Dizziness or vertigo when you walk or get up from a chair or bed?	
No
Yes

    12. Has a doctor ever told you that you have…
    e. Arthritis, Bone or Joint problems affecting your mobility, legs, hips, knees, ankles or feet?	
No
Yes

    13. Do you have…
    f. Paralysis of a leg or foot?	
No
Yes
    g. An amputation of a leg, foot or toe?	
No
Yes
    h. Impaired vision that cannot be corrected or are you blind?	
No
Yes
    • Medications
    14. Are you currently taking any prescription medications?	No	Yes
If Yes, how many different medications do you take per day?	1-3    4-6   7-10	More than 10
    15. Are you currently taking any non-prescription or over the counter medications?	No	Yes
If Yes, how many different medications do you take per day?	1-3    4-6   7-10	More than 10
    16. Do you ever forget to take a medication or decide not to take one?	No	Yes
If Yes, About how often does this happen? 1-3 times/wk    4-6 times/wk     More than 6 times/wk
   Why does this happen?        Forgets              Too expensive   Other: _______________
    17. Do you take medication for any of the following conditions?

No
Yes

No
Yes
Anxiety	


Stress	


Depression	


Memory loss or Memory Impairment	


    18. Have you ever been treated for Depression?	No	Yes
If Yes, Are you currently being treated for depression? 	No	Yes
    • Falls History and Risks

    19. How many times in the past 6 months have you had an episode of fainting, falling or dropping to the ground or lost your balance, slipped or tripped over something that resulted in falling or dropping to the ground?	_____ Times
a) If one (1) or more times, Did you get hurt? 	No	Yes
b) What has been your most serious injury or problem due to any fall? (check all that apply)
Never Injured    Bruises   Cuts  Discomfort  Fracture of leg    Fracture of wrist or arm   
Fracture of back/vertebrae   Head injury                Other (specify)__________________
c) How long were you on the ground before you could get up?  ________________

    20. Do you ever limit your activities, for example, what you do or where you go because you are afraid of falling?	No	Yes
    21. Some things help to prevent falls. Do you currently do any of these?
a) Exercise program	No	Yes
     If “Yes” what type?    Yoga    Stretching   Tai Chi  Walking  Weights/Strengthening exercises
Swimming             Other (Specify) __________________

b) Regularly see your doctor	No	Yes
c) Participate in a community based fall prevention program	No	Yes
-------- previously we asked have you EVER participated in falls prevent. Program   do we want to ask this?
    • Modified Geriatric Depression Scale (GDS IV)
    1. Please choose the best answer for how you have felt over the past week. 
Assessor, yes and no check boxes reverse depending on whether the question is posed as positive or negative.

Question
Not
Depressed

Depressed
1
Are you basically satisfied with your life?	
Yes
No
2
Have you dropped many of your activities and interests?	
No
Yes
3
Are you afraid that something bad is going to happen to you?	
No
Yes
4
Do you feel happy most of the time?	
Yes
No

Total number of Depressed answers:

    • TICS
    2. Next, I am gong to ask you some questions to test your memory.  Some of these are likely to be easy for you, but some may be difficult.  Please bear with me and try to answer all the questions as best you can.  If you can’t answer a question, don’t worry, just try your best.  If you have a television or radio on, please turn it off so that you are not distracted for this part of the interview.  Are you ready? 	No	Yes
If No, why not?Refused to completeOther, explain_________________________________

Question
Answer
Correct
Incorrect
Please tell me your full name	First:



	Last:



What is today’s date? 	Month:



	Day:



	Year:



	Day of week:



	Season:



Where are you right now? 	Number:



	Street:



	City:



	State:



	Zip Code:



Please count backwards from 20 to 1 	1st try:



If error: Please count backwards from 20 to 1 	2nd try:



I am going to read to you a list of 10 words.  Please listen carefully and try to memorize them.  When I am done, tell me as many of the words as you can in any order .  Ready?  OK, the words are…Assessor – say each word slowly and use clear enunciation.  Pause for 1 second after each word is said..
Cabin 	Check if recalled:



Pipe 	Check if recalled:



Elephant 	Check if recalled:



Chest 	Check if recalled:



Silk 	Check if recalled:



Theater 	Check if recalled:



Watch 	Check if recalled:



Whip 	Check if recalled:



Pillow 	Check if recalled:



Giant 	Check if recalled:



I would like you to take the number 100 and subtract 7 	Answer:



Now keep subtracting 7 from the answer Until I tell you to stop 	Answer:



   	Answer:



	Answer:



	Answer:



What do people usually use to cut paper? 	Answer:



How many things are in a dozen? 	Answer:



What do you call the prickly green plant that lives in the desert? 	Answer:



What animal does wool come from? 	Answer:



Please repeat this after me “No ifs, ands or buts” 	Answer:



Now please repeat this after me “Methodist Episcopal” 	Answer:



With the tip of your finger, tap 5 times into the part of 	Taps are heard:



    the phone you speak into.	Total number of taps = 5:



I am going to say a word and I want you to give me its opposite.  For Example, if I said “hot” you would say “cold”
What is the opposite of west?	Answer:



	Total correct:_________

    • Ambulation
    3. Do you have difficulty walking without help from another person?	No	Yes
    4. Do you have difficulty getting in and/or out of your home?	No	Yes
    5. Do you have difficulty walking from one room to another inside your home? 	No	Yes
    6. Do you have difficulty walking inside your home without the use of furniture or other items to steady yourself?	No	Yes
    7. Do you have any electrical cords, furniture or clutter that cross walkways, hallways or pathways in your home?	No	Yes
    8. Do you have any slippery throw rugs (scatter rugs) in your home that are not fastened to the floor?	No	Yes
    9. Do you have difficulty getting around outside your home within walking distance including negotiating uneven surfaces?	No	Yes
    • IADL/ADL Evaluation
    10.  Do you have difficulty doing any of the following activities without help from another person? 
    a) TAKING YOUR MEDICATIONS: (opening bottles, measuring correct doses, taking them at the correct time)?	No	Yes
    b) USING THE TELEPHONE: (answering the phone. looking up numbers and dialing)?	No	Yes
    c) MANAGING YOUR FINANCES: (paying bills, writing checks, balancing your checkbook)?	No	Yes
    d) DOING YOUR HOUSEWORK: (making beds, dusting, vacuuming, cleaning the floors, the kitchen and bathroom)?	No	Yes
    e) DOING YOUR LAUNDRY: (transferring clothes to/from washer/dryer, and putting clean items away)?	No	Yes
    f) SHOPPING FOR GROCERIES: (getting to store, obtaining, paying for, carrying home and putting away all needed items)?	No	Yes
    g) TRANSPORTING YOURSELF: (driving or arranging a ride, getting to/from and in/out of the vehicle by yourself)?	No	Yes
    h) PREPARING YOUR MEALS: (planning, preparing and serving complete, well-balanced meals)?	No	Yes

    i) GETTING IN AND OUT OF A BED OR CHAIR?	No	Yes
i)  Getting in and out of a chair without using your hands to push off?	No	Yes
ii)  Getting up from the floor without help from another person?	No	Yes
    j) DRESSING AND UNDRESSING YOURSELF?	No	Yes
    k) BATHING YOURSELF?	No	Yes
i)  Getting in and out of your bathtub or shower?	No	Yes
    l) FEEDING YOURSELF?	No	Yes
    m) TOILETING?	No	Yes
i)  Getting on or off of your toilet?	No	Yes
    n) MAINTAINING CONTINENCE OR CARING FOR PERSONAL HYGIENE AFTER INCONTINENCE OCCURS?	No	Yes

    11. Do you have non-slip surfaces/mats inside and outside your tub/shower?	No	Yes


    • Medical Equipment
    12. In the last week or so, have you used any of the following medical equipment or devices?  (if “Yes,” explain below)


No
Yes

No
Yes

No
Yes
Wheelchair	


Electric Chair Lift	


Bedside Commode	


Walker	


Electric Stair Lift	


Urinary Catheter	


Cane	


Electric Cart or Scooter	


Oxygen Equipment	


Crutches	


Raised Toilet Seat	


Grab Bars in Tub or Shower	


Prosthesis/Leg Braces	


Toilet Safety Frame/grab bar	


Other:		



If “Yes,” Why do you use the equipment?	
		
		Where do you use this equipment?      In the home            Outside  
		   Approximately how much of your own money did you spend on this equipment?
I did not spend my own money	less than $50	$50-$100	$101-$150
$151-$200	$201-$250	$251-$300	don’t know/came with house 
Other amount__________

    13. Have you made any modifications to the outside or inside of your home to improve its safety?	No	Yes
If Yes, what type of modification(s):   	
            Why?	
		Approximately how much of your own money did you spend to improve your home’s safety?
I did not spend my own money	less than $50	$50-$100	$101-$150
$151-$200	$201-$250	$251-$300	other amount__________
    • Height and Weight
    14. What is your height?  _____ ft _____in

    15. What is your weight? ____________lbs

    • Visual Acuity
    16. Do you have glasses or contact lenses? 	No	Yes
Do you wear them	Most of the time     Sometimes     For special reasons (such as driving or reading) 
Never
    17. Have you had an eye exam or your vision checked by a doctor or optometrist in the last five years? 	No	Yes
    18. Can you see well enough (with glasses, if needed) to read the newspaper?	No	Yes 
    19. Can you see well enough (with glasses, if needed) to watch television? 	No	Yes
    20. Can you see well enough (with glasses, if needed) to read writing on television? 	No	Yes
    21. Can you see well enough (with glasses, if needed) to read medicine bottles? 	No	Yes
    22. Can you see well enough (with glasses, if needed) to walk downstairs in daylight? 	No	Yes
    23. Can you see well enough (with glasses, if needed) to walk downstairs in dim light? 	No	Yes
    24. Can you see well enough (with glasses, if needed) to recognize someone across the room? 	No	Yes
    • Physical Activity Scale for the Elderly (PASE)
Now I am going to ask you some questions about your daily activities.  Please let me know if in the past 7 days you have done any of these activities.  

Household Activity
During the past 7 days…
    25. Have you done any light housework, such as dusting or washing dishes?	No	Yes
    26. Have you done any heavy housework/chores, such as vacuuming, scrubbing floors, washing windows, or carrying wood?	No	Yes

Did you engage in any of the following activities?
    27. Home Repairs like painting, wallpapering, electrical work etc…	No	Yes
    28. Lawn work or yard care including snow or leaf removal, wood chopping, etc…	No	Yes
    29. Outdoor Gardening	No	Yes
    30. Caring for another person such as children, dependent spouse or another adult?	No	Yes


Work Related Activity
    31. During the past 7 days did you work for pay or as a volunteer?  (If “Yes,” explain below)	No	Yes
A. How many hours did you work in the past 7 days?
B. Which best describes the activities that are required at your work
1-8 hours
Mainly sitting with slight arm movements 
(Office worker, watchmaker, assembly line worker, bus driver)
9-20 hours
Sitting or Standing with some walking 
(Cashier, general office worker, light tool and machinery worker)
21-30 hours
Walking with some handling of material generally weighing less than 50 lbs. 
(Mailman, waiter/waitress, construction or heavy tool/machinery worker)
31-40 hours
Walking and heavy manual work often handling materials over 50 lbs.
(Lumberjack, stone mason, farm or general laborer)


Leisure-Time Activity
Over the past 7 days, did you…
    32. Take a walk outside your home or yard for any reason?  (e.g.: for fun exercise, walking to work, walking the dog, etc)	No	Yes
	If Yes, How many days in the past week did you walk?  __________
		On Average, how many minutes per day did you spend walking?  ________

    33. Engage in light sport or recreational activities such as bowling, golf with a cart, shuffleboard, fishing from boat or pier or other similar activities?	No	Yes
	If Yes, How many days in the past week did you participate in these activities?  __________
		On Average, how many minutes per day did you spend doing these activities?  ________

    34. Engage in moderate sport and recreational activities such as doubles tennis, ballroom dancing, hunting, ice skating, golf without a cart, softball or other similar activities?	No	Yes
	If Yes, How many days in the past week did you participate in these activities?  __________
		On Average, how many minutes per day did you spend doing these activities?  ________

    35. Engage in strenuous sport and recreational activities such as jogging, swimming, cycling, singles tennis, aerobic dance, skiing (down hill or cross country) or other similar activities?	No	Yes
	If Yes, How many days in the past week did you participate in these activities?  __________
		On Average, how many minutes per day did you spend doing these activities?  ________

    36. Do any exercise specifically to increase muscle strength/endurance such as lifting weights, doing push-ups,. Sit-ups etc?	No	Yes
	If Yes, How many days in the past week did you participate in these activities?  __________
		On Average, how many minutes per day did you spend doing these activities?  ________
    37. Do any exercise specifically to increase balance or flexibility (stretching) such as yoga, Tai Chi,  etc?	No	Yes
	If Yes, How many days in the past week did you participate in these activities?  __________
		On Average, how many minutes per day did you spend doing these activities?  ________


    • Demographics
    38. What is your marital status?	Married	Widowed	Divorced	Never Married
    39. What is your date of birth?_____/_____/______
    40. What is your gender	Male	Female
    41. What is your highest level of education?      	Less than high school graduate      High School graduate	
 Some college or Associate’s Degree	College graduate     Graduate Degree
    42. Which of the following describes your race?	White     African American or Black     Asian      American Indian    
	Native Hawaiian or other Pacific Islander   	Other race ________________    Hispanic or Latino
Refused to disclose/Uncertain
    43. To get a picture of people’s financial situation, we need to know your total household income from all sources, before taxes in (YEAR).  This includes social security, retirement income, job earnings, dividends, public assistance, help from relatives and any other source of income you may have.  Would you say that your household income was  	Less than $50,000    $50,000 or greater?
Was it: 

	If less than $50,000	If greater than or equal to $50,000  	

	  Under $25,000	  Under $75,000 ($50,000-$74,999)	
	  Under $35,000 ($25,000-$34,999)			  Under $100,000 ($75,000-$99,999)
	  Under $50,000 ($35,000-$49,999)			  Under $150,000 ($100,000-$149,999)
	  Don’t know					  $150,000 and over
	  Refused					  Don’t know
							  Refused

    • Wrap up
INITIAL CONTACT- Talking to insured
Thank you for taking the time to answer my questions, we really appreciate your contribution.  In the near future, you will receive an Exercise Progress Chart and a Falls Journal in which you can record any falls or near falls that may occur.  You may also receive another telephone call shortly to set up an interview in your home, or we will be in touch with you couple of months to see how you are doing.

INITIAL CONTACT- Talking to proxy
Thank you for taking the time to answer my questions, we really appreciate your contribution.  In the near future, (name of insured) will receive an Exercise Progress Chart and a Falls Journal in which you can record any falls or near falls that may occur.  You may also receive another telephone call shortly to set up an interview in (name of insured’s) home, or we will be in touch with you in a couple of months to see how (name of insured) is doing.

FINAL CONTACT- Talking to insured or proxy
Thank you for taking the time to answer my questions, we really appreciate your contribution to this important research Program.  I want to thank you once again for participating in the Independent Living and Mobility Program your contributions may result in safer practices and home environments for older adults.
    • Clinical Summary:  Provide an answer for each question
	
    44. Do you believe that the participant would have difficulty performing any of his/her IADL’s and ADL’s without assistance from another person due to an impairment?	No	Yes
  If Yes, due to cognitive impairment	No   Yes
   If Yes, due to physical impairment	No   Yes
If Yes to either, explain	
    45. Did the participant appear apathetic or require prompting or motivating to answer questions or complete the interview?	No	Yes
If Yes, explain: 	
	
    46. Was there evidence of sad or depressed mood or flattened affect?	No	Yes
If Yes, explain: 	
	

    47. Did the participant have difficulty following directions?	No	Yes
If Yes, explain:	
		

    48. Was the participant unable to answer any questions or did the participant refuse to answer any of the questions?	No	Yes
If Yes, explain: