Jump Start phone call

Form Approved

OMB No. 0990-0308

Exp. Date XX/XX/20XX

JUMP START PHONE CALL FOR LIFT WELLNESS PROGRAM

Participant Name: autofill Date of Birth: autofill

INTRODUCTION -- To be read at the beginning of the Jump start Phone call:

Hi, my name is __________________________ and I am calling on behalf of the LIFT Wellness Program. Recently, you had a series of interviews as part of the program and an Action Plan was sent to you along with some free materials. I am calling to be sure that you received all the materials about the program and to see if you have any questions about what we sent. Do you have a few minutes to speak with me now?

If yes, continue

If no, schedule a call back time.

If they don’t want to take the call at all, or for any other responses, please disposition appropriately.

1. I want to make sure you received all of the materials we sent. Did you receive:

• The action plan …………………………………………..Yes No

• The fee toolkit with pedometer and exercise program ….Yes No

• The falls diary…………………………………………….Yes No

• The exercise diary………………………… ……………..Yes No

a. If yes, continue with question 2.

b. If no “I am sorry to hear that. The Welcome Kit was mailed out. Can you please confirm your address?” Correct Address Incorrect Address

• If the address confirmed is the correct one say -- “I am sorry that you have not yet received this information. The address you gave me is the place where the Welcome Kit was sent. We will send another Welcome Kit to you. You should receive it in about a week. I’ll give you some time to read over the materials and call you back in about two weeks to follow up again. Thanks for your time today.” {END CALL}

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 30 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

• If the address is incorrect, obtain the correct address:

Address:_________________________________________

__________________________________________

“I am sorry that you did not receive the Welcome Kit. We evidently sent it to the wrong address. We will send a Welcome Kit to the address that you just gave me. You should receive it in about a week. I’ll give you some time to read over the materials and call you back in about two weeks to follow up again. Thanks for your time today.” {END CALL}

2. Have you had a chance to review the materials that were sent to you? ……..Yes No

1. If yes, review the Action Plan with them at a high level and ask:

Do you have any questions about the recommendations made?……..……..Yes No

• If yes, please note the questions in the space below:

• If no, continue with question 3.

2. If no, I would like to go over the personalized recommendations made for you. Do you have the Action Plan nearby so we can take a minute to review it or would you rather we set up a time for me to call back and go over it with you?

Reviewed with participant (ask 2a above and continue)

Scheduled call back

3. A copy of your personalized Action Plan was sent to the doctor you said was responsible for your primary care. We encourage you to make an appointment with that doctor and review the findings and recommendations on the Action Plan.

Are you planning to make or have you made an appointment to speak with your Doctor about the results of the Action Plan? Yes No

• If yes – “I am glad to hear that. It is important that your doctor is kept up to date on your health status. Your doctor may also have some other suggestions for prevention of falls.”

• If no – We really encourage you to see your doctor, he or she is an important part of remaining independent and healthy, as well as a good resource on preventing falls. Do you mind my asking why you don’t plan to see your doctor about the Action Plan recommendations? Note reasons in the space below

4. “Are you planning to do any of the things that were recommended in the Action Plan?”

Yes, Which ones? Document below:

No, Really, why not? Document below and read paragraph

Studies show that one out of every three individuals over the age of sixty-five fall every year! This is one of the reasons that implementing the suggestions in the Action Plan is important. You may find that by doing all or even some of the things suggested, you may have more energy, feel stronger and are able to be independent in your home and community.

5. Do you need any help with any of the suggestions for services (if there are any such suggestions)?”

Yes, I have some resources that I can give you that you might find helpful. They are provided through the ElderCare Locator, a public service of the U.S. Administration on Aging. The Eldercare Locator is the first step to finding resources for older adults in any U.S. community. Just one phone call or Website visit provides an instant connection to resources that enable older persons to live independently in their communities. The service links those who need assistance with state and local area agencies on aging and community-based organizations that serve older adults and their caregivers. Would you like that information?”

You can speak with an Eldercare Locator information specialist by calling toll-free at 1-800-677-1116 weekdays, 9:00 a.m. to 8:00 p.m. (ET). OR

You can browse the internet, on the ElderCare Locator website -- www.eldercare.gov/Eldercare/Public/Home.asp

No

Thanks for your time today. I hope that I was able to answer any questions that you had as well as give you some information about the importance of implementing the suggestions in your Action Plan. I’ll be calling you again in about three months, to follow up on your progress and see how you are doing with the Action Plan recommendations. What is the best phone number to reach you in (month and year you will be calling)?

Record phone number

Please use the items provide in the free toolkit to help you. If you have any questions, please feel free to call me at 1-800-525-7279 and my extension is XXX.

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