Quarterly telephone calls

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

0990-0308 Appendix G

Quarterly telephone calls

OMB: 0990-0308

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APPENDIX G



QUARTERLY TELEPHONE INSTRUMENT


Form Approved

OMB No. 0990-0308

Exp. Date XX/XX/20XX




R


eferral Number:




Participant Name:

Address:

Phone Number:





Independent Living and

Mobility Program


Quarterly Follow-up


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 10 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


My name is ______________, and I am calling in regard to the Independent Living and Mobility Program. I am calling to get updated information regarding your current Exercise Routine and to see how you have been doing since we last contacted you. The interview will take approximately 5-15 minutes. Is this a good time?


If not, schedule a time to call the participant back to complete phone screen.

  • General Questions

  1. Since we last talked, have you seen your primary care doctor? No Yes


  1. Since we last talked, have you had any new symptoms or been diagnosed with any new conditions? No Yes


Condition

Date of Diagnosis/

1st 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



  1. Since we last talked, have you started any new medications? No Yes


Medication Name

Dosage

Frequency

If PRN, indicate how often used?

Reason for taking

1






2






3







  1. Since we last talked, have you discontinued any medications? No Yes


Medication Name

Reason stopped taking

1



2



3




  1. Since we last talked, have you had any changes in any of your medication dosages or how often you take them? No Yes


Medication Name

Dosage

Frequency

If PRN, indicate how often used?

1





2





3






  1. Since we last talked, have you had any new treatments prescribed or recommended? No Yes


If Yes, What type of treatment? Physical Therapy Occupational Therapy

Other:

Why?

  1. Since we last talked, have you had any Hospital Admissions, Emergency Room visits or Surgery? No Yes

If Yes, indicate number of times: _________times and supply details below:


Reason for Hospital Admission/ Emergency Room visit/ Surgery

Date (month/year)

Type of Surgery &/or

Treatment received

Current Status

1





2





3






  1. Since we last talked, have you changed your primary care doctor? No Yes

If Yes, Why?

New Physician’s name: Phone number:

City: State Street address:

Specialty:

  • Exercise History

The next questions refer to your exercise routine.


  1. Have you been filling in the Exercise Progress Chart on a daily or weekly basis? No Yes

If Yes, you may want to refer to it as you answer the next few questions


  1. In the past 7 days have you participated in any exercise? No Yes


If Yes, How many days (in the past week)? 1 day 2 days 3 days 4 days

5 days 6 days 7 days


How many hours per day?

<1 hr but more than 30 min 1 hour >1 hr but less than 2 hr 2 hours

>2 hr but less than 3 hr 3 hours >3 hours Other:__________

What type of exercise?

Endurance= increase breathing/heart rate (brisk walk, stairs, swim, aerobics, jog, cycle, tennis, dance, shovel, ski, hike, rake/row lawn, mop/scrub floor)

Strength= build muscles (weights, chair stands, arm/leg raises, hip/knee/shoulder flexion/extension, sit-ups, push-ups)

Balance= improve/maintain balance (heel-to-toe walk, stand on one foot, strength exercises using one hand/one finger for holding on or not holding on)

Flexibility= stretching to improve freedom of movement (arm, shoulder, wrist, leg, ankle, hip and neck stretching)


  1. Has this been your typical routine over the past 3 months? No Yes


If No, How often do you usually exercise? 1 day/wk 2 days/wk 3 days/wk 4 days/wk

5 days/wk 6 days/wk 7 days/wk


How many hours per day?

<1 hr but more than 30 min 1 hour >1 hr but less than 2 hr 2 hours

>2 hr but less than 3 hr 3 hours >3 hours Other:__________


What type of exercise?

Endurance= increase breathing/heart rate (brisk walk, stairs, swim, aerobics, jog, cycle, tennis, dance, shovel, ski, hike, rake/row lawn, mop/scrub floor)

Strength= build muscles (weights, chair stands, arm/leg raises, hip/knee/shoulder flexion/extension, sit-ups, push-ups)

Balance= improve/maintain balance (heel-to-toe walk, stand on one foot, strength exercises using one hand/one finger for holding on or not holding on)

Flexibility= stretching to improve freedom of movement (arm, shoulder, wrist, leg, ankle, hip and neck stretching)

Why have you not been following your typical exercise routine?

  1. Would you like for us to mail you some more Weekly Schedules for your Exercise Progress Chart? No Yes


  • Falls History

The next questions refer to any fall that you may have experienced in since we last contacted you.


  1. Since our last call, have you had one or more episodes of fainting, falling or dropping to the ground, passing out or have you lost your balance or tripped over something that resulted in falling or dropping to the ground? No Yes

If Yes, How many times did this happen?


Do you fill out the Fall Journal whenever you have a fall? No Yes

If Yes, you may want to refer to it as you answer the next few questions


What time of day did you fall? 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 sustain any injuries? No Yes

Did you require Medical Attention? No Yes

Doctor Visit Hospital Admission Emergency Room Visit


What were you doing when you fell?


Were you at home when you fell? No Yes

If Yes, Where? Bathroom Kitchen Stairs Entryway 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?

Ground conditions


Behaviors For each Yes*, answer additional *question* below

Wet Ground

No Yes

Wearing shoes that did not fit properly

No Yes*

Icy/snowy Ground

No Yes

Wearing clothes that did not fit properly

No Yes*

Uneven Ground

No Yes

Not using necessary visual aid/glasses

No Yes*

Stepping up onto/down from a Curb

No Yes

Not using necessary equipment

No Yes*

Climbing up/going down stairs

No Yes

(cane, walker, shower seat, grab bars)


Object in walkway/path

No Yes




*Have you changed this behavior to prevent future falls? No Yes


  1. Have you been anxious, worried or afraid you might fall? No Yes

  2. 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, Explain:


  1. Since we last talked, have you made any changes to your home or to your behavior to prevent future falls? No Yes

If Yes, which activities and why?

How often? All of the time Some of the time Rarely Doesn’t know


Have you spent any of your own money to implement any of these changes? No Yes

If Yes, how much? $_________

Were you reimbursed for any of these expenses? No Yes


  1. Since we last talked, are you less fearful of falling? No Yes

If Yes, Explain why:

  • Wrap up

Thank you again for participating in the Falls Preventions study. We will be calling you in another three months to see how you are doing.


  1. Is there a best day of the week and/or time of day for us to call you so that the interview will be convenient for you? No Yes


If Yes, Day of week? Sun Mon Tues Wed Thur Fri Sat

Time of day? 8am-12pm 12pm-4pm 4pm-8pm Other:__________

Eastern Central Mountain Pacific



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Abt Associates and Center for Health and Long Term Care Research

The Effect of Reducing Falls on Long Term Care Expenses – Literature Review

File Typeapplication/msword
File TitleAPPENDIX A
AuthorLifePlans
Last Modified ByDHHS
File Modified2013-06-28
File Created2006-02-01

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