HUD Residents Living Alone (3-person household)

HUD Supportive Services Demonstration/Integrated Wellness in Supportive Housing (IWISH)

2-15-18 IWISH_ResidentAssessment

HUD Residents Living Alone (3-person household)

OMB: 2528-0315

Document [docx]
Download: docx | pdf

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HUD’s Integrated Wellness in Supportive Housing (IWISH)

Resident and Wellness Assessment –

Paper Version - DRAFT



PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN:

The public reporting burden for this information collection is estimated to be 80 minutes. This burden estimate includes time for reviewing instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the information. Send comments regarding the accuracy of this burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Federal Investigative Services, Attn: OMB Number (3206-0246), 1900 E Street NW, Washington, DC 20415-7900.

The information requested under this collection is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C.552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.

Please use this paper version of the health and wellness assessment for times when you cannot enter information directly into the demonstration’s online platform, hosted by Population Health Logistics (PHL). After completing the paper assessment, please follow the IWISH PHL User Guide for instructions on how to enter the data into PHL.





Participant Information

  1. First Name


  1. Middle Name


  1. Last Name


  1. Date of Birth


  1. Gender (select one)

Male Female Transgender Does Not Declare Other

  1. Preferred Language (select one)

English Spanish Albanian Arabic Cambodian

Chinese-Cantonese

Chinese –Mandarin Farsi

French Creole German

Greek Hindi Italian

Korean Persian

Portuguese Russian Tagalog

Twi Ukrainian

Vietnamese Other _____________

  1. Date(s) of Assessment






  1. Marital Status (select one)

Married Never Married

Divorced Single

Widowed Separated

Other ______________

  1. Race/Ethnicity (select all that apply)

American Indian or Alaska Native

Asian

Black or African American

Hispanic

Native Hawaiian or Other Pacific Islander

White

Other _______________

  1. Social Security Number

________ - ______- _________

  1. Veteran

Yes No

  1. Was the Participant Information section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



Participant Contact Information

Add Address

  1. Address Type

Home Mailing Other

  1. Address 1


  1. Address 2


  1. City, State, Zip


  1. Primary Address

Yes No

Add Phone

  1. Phone Number Type

Home Mobile Work Other

  1. Phone Number

_____-_____-______

  1. Primary Phone

Yes No

Add Email

  1. Email Type (select one)

Personal Family Member Email Address

Other

  1. Email Address


  1. Primary Email

Yes No

  1. Was the Participant Contact Information section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions




Insurance

*Ability to add multiple insurance policies. Space for two is included below.

  1. Insurance Number

  1. Insurance Type (select one)

Medicare Part A (Hospital Coverage)

Medicare Part B

Medicare Part C (Medicare Advantage)

Medicare Part D (Prescription Coverage)

Medicare Supplemental (Medigap)

Medicaid

PACE

Tricare

Veteran’s Affairs

Commercial Insurance

Uninsured Other

  1. Insurance Number

  1. Insurance Type (select one)

Medicare Part A (Hospital Coverage)

Medicare Part B

Medicare Part C (Medicare Advantage)

Medicare Part D (Prescription Coverage)

Medicare Supplemental (Medigap)

Medicaid

PACE

Tricare

Veteran’s Affairs

Commercial Insurance

Uninsured

Other

  1. Insurance Number

  1. Insurance Type (select one)

Medicare Part A (Hospital Coverage)

Medicare Part B

Medicare Part C (Medicare Advantage)

Medicare Part D (Prescription Coverage)

Medicare Supplemental (Medigap)

Medicaid

PACE

Tricare

Veteran’s Affairs

Commercial Insurance

Uninsured

Other

  1. Was the Insurance section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



Contacts

*Ability to add multiple contacts. Space for three contacts is included below.

Contact Details – Contact #1

  1. Full Name (of contact)


  1. Relationship to Participant (select one)

Spouse Son Daughter Daughter-in-law

Son-in-law Sister Brother Spouse Equivalent

Friend Neighbor Granddaughter

Grandson Nephew Niece Other

  1. Power of Attorney (POA) (select one)

Health Care Financial Health Care and Financial

Not Applicable

  1. Guardian (select one)

Yes

No

Pending

  1. Contact Method Preference (select one)

Phone Email

Phone or Email

Fax Mail

Other

  1. Frequency of participant meeting with this contact (select one)

Daily 2-3 times weekly Weekly

2-3 times/month Several times/year As-needed

Other

  1. Primary Contact

Yes No

  1. Emergency Contact

Yes No

  1. Caregiver

Yes No

  1. Household (i.e., does this contact live in participant’s home?)

Yes No

  1. Address Type

Home Other

  1. Primary Address

Yes No

  1. Address

  1. City, State, Zip


  1. Phone Number Type

Home Mobile

Work Other

  1. Phone Number

_____-_____-_______

Ext: (_______)

  1. Primary Phone

Yes No

  1. Email Type (select one)

Personal

Family Member

Office Other

  1. Primary Email

Yes

No

  1. Email Address


Contact Details – Contact #2 (if applicable)

  1. Full Name (of contact)


  1. Relationship to Participant (select one)

Spouse Son Daughter Daughter-in-law

Son-in-law Sister Brother Spouse Equivalent

Friend Neighbor Granddaughter

Grandson Nephew Niece Other

  1. Power of Attorney (POA) (select one)

Health Care Financial Health Care and Financial

Not Applicable

  1. Guardian (select one)

Yes

No

Pending

  1. Contact Method Preference (select one)

Phone Email

Phone or Email

Fax Mail

Other

  1. Frequency of participant meeting with this contact (select one)

Daily 2-3 times weekly Weekly

2-3 times/month Several times/year As-needed

Other

  1. Primary (i.e., primary contact)

Yes No

  1. Emergency Contact

Yes No

  1. Caregiver

Yes No

  1. Household (i.e., does this contact live in participant’s home?)

Yes No

  1. Address Type

Home Other

  1. Primary Address

Yes No

  1. Address


  1. City, State, Zip


  1. Phone Number Type

Home Mobile

Work Other

  1. Phone Number

_____-_____-_______

Ext: (_______)

  1. Primary Phone

Yes No

  1. Email Type (select one)

Personal

Family Member

Office

Other

  1. Primary Email

Yes No

  1. Email Address


Contact Details – Contact #3 (if applicable)

  1. Full Name (of contact)


  1. Relationship to Participant (select one)

Spouse Son Daughter Daughter-in-law

Son-in-law Sister Brother Spouse Equivalent

Friend Neighbor Granddaughter

Grandson Nephew Niece Other

  1. Power of Attorney (POA) (select one)

Health Care Financial Health Care and Financial

Not Applicable

  1. Guardian (select one)

Yes No Pending

  1. Contact Method Preference (select one)

Phone Email

Phone or Email

Fax Mail

Other

  1. Frequency of participant meeting with this contact (select one)

Daily 2-3 times weekly Weekly 2-3 times/month

Several times/year As-needed Other

  1. Primary (i.e., primary contact)

Yes No

  1. Emergency Contact

Yes No

  1. Caregiver

Yes No

  1. Household (i.e., does this contact live in participant’s home?)

Yes No

  1. Address Type

Home Other

  1. Primary Address

Yes No

  1. Address


  1. City, State, Zip


  1. Phone Number Type

Home Mobile

Work Other

  1. Phone Number

_____-_____-_______

Ext: (_______)

  1. Primary Phone

Yes No

  1. Email Type (select one)

Personal

Family Member

Office Other

  1. Primary Email

Yes No

  1. Email Address


  1. Was the Contacts section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

Participant Resources

Specify which resources/services the participant currently receives in this section.

Please use one row for each service and specify the Agency Type, the Category of Service Provided, the Type of Service, Date Service Began, and Current Service Status.

A table listing the different types of services for each category is available following this section.


Service Number

Agency Type

Service Category

Service Type

Date Service Began

Service Status


Indicate one:

  • Your own IWISH site

  • Adult Day Care

  • Area Agency on Aging

  • Home Health Agency

  • Mental Health Agency

  • Primary Care

  • Specialty Care

  • Transportation Agency

  • Other

Indicate one:

  • Case Management Services

  • Food

  • Housing

  • Home Modification

  • Utility Assistance

  • Transportation

  • Medical

  • Financial

  • Legal

  • Employment

  • Education

  • Other

See choices following this table

If known

Indicate one:

  • Currently Received

  • Denied

  • Pending

  • Waitlisted

  • Other





















































  1. Was the Resources section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



Participant Resources: Category of Services and Associated Type of Service

Please use this table as a reference when completing the Participant Resource portion that precedes this section. This table defines the types of services within each service category.

Category of Service

Type of Service

Case Management Services

  • Case management

  • Homemaker services

  • Level of care assessment

  • Options/benefits counseling

  • Personal care services

  • Other case management services

Food

  • Home delivered meals

  • Congregate meals

  • SNAP (food stamps)

  • Pantry/food bank

  • Nutrition education

  • Other food/nutrition

Housing

  • Hoarding

  • Lease compliance

  • Other housing services

Home Modification

  • Home safety assessment

  • Accessibility modifications

  • Other home modification

Utility Assistance

  • Low Income Home Energy Assistance Program (LIHEAP)

  • Other utility assistance

Transportation

  • Transportation voucher/ride program

  • Medical transportation

  • Driver Safety

  • Other transportation

Medical


  • Alcohol use

  • Chronic condition management

  • Cognitive health

  • Dental

  • Emergency room use

  • Exercise/ physical activity

  • Falls

  • Financial assistance

  • Hearing

  • Hospice/ palliative care

  • Immunizations/ screenings

  • Medications

  • Medical supplies/ equipment

  • Mental health

  • Pain Management

  • Provider/ pharmacy access and relationships

  • Therapy (occupational, physical, speech)

  • Tobacco cessation support

  • Visual

  • Weight management

  • Other medical

Financial

  • Budgeting/ financial planning

  • Income/benefits

  • Insurance

  • Other financial

Legal

  • Adult protective services

  • End of life planning (will, advance directive, DNR, etc.)

  • Guardian

  • Power of attorney (financial, medical)

  • Other legal

Employment

  • Full/part-time employment

  • Senior employment program

  • Other employment services

Education

  • Language

  • Literacy

  • Lifelong learning

  • Other education

Other

  • Caregiver support

  • Interpersonal relationships (family, friends)

  • Pets (care, support/needs)

  • Recreation/ social activities

  • Spirituality/ religious participation

  • Support groups

  • Volunteering/ community service

  • Other social support or engagement





Immunizations

Immunization

Status (select one)

Approximate Immunization Date

Notes

  1. Influenza

Yes

No

Unknown

No - Medical Reason



  1. Pneumovax

Yes

No

Unknown

No - Medical Reason



  1. Prevnar

Yes

No

Unknown

No - Medical Reason



  1. Shingles

Yes

No

Unknown

No - Medical Reason



  1. Other:__________

Yes

No

Unknown

No - Medical Reason



  1. Other:__________

Yes

No

Unknown

No - Medical Reason



  1. Other:__________

Yes

No

Unknown

No - Medical Reason



  1. Other:__________

Yes

No

Unknown

No – Medical Reason



  1. Was the Immunization section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



General Information

Advance Directive, DNR, and POAs

  1. Does participant have a documented Advance Directive?

Yes No Unknown

  1. If no, would the participant like assistance creating an Advance Directive?

Yes No Not Now N/A

  1. Advance Directive Agent’s Name and Contact Information


  1. Where is Advance Directive stored? (select all that apply)

Family Member Home

MD Office Preferred Hospital

Other N/A

  1. Does the participant have a Do Not Resuscitate (DNR) order?

Yes No Unknown

  1. Who, if anyone, has a copy of the participant’s DNR?

Family Member MD Office

Healthcare Power of Attorney

Preferred Hospital

Other N/A

  1. Does the participant have a Health Care Power of Attorney?

Yes No Unknown

  1. Contact information for who, if anyone, has a copy of the participant’s Health Care Power of Attorney?


  1. Does the participant have a Financial Power of Attorney?

Yes No Unknown

  1. Contact information for who, if anyone, has a copy of the participant’s Financial Power of Attorney?






Household, Assistive Devices, and Transportation

  1. Does the participant have a Personal Emergency Response System (PERS) such as Lifeline or Link to Life?

Yes No

  1. Mode(s) of Transportation (select all that apply)

Own Car

Bus

Support Person

Transportation Agency

Other

  1. Notes for the General Information Section:
















  1. Was the General Information section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions









































Clinicians

Please include the participant’s Primary Care Provider and key specialists the participant regularly visits.

Primary Care Provider

  1. Primary Care Provider’s full name



  1. Phone

_____-_____-________

  1. Fax

_____-_____-________

  1. Email


  1. Practice Name and Address


Specialist #1

  1. Specialist Full Name



  1. Specialty (select one)

Oncologist Neurologist

Psychologist Psychiatrist

Cardiologist Ophthalmologist/Optometrist

OBGYN

Other _______________________

  1. Phone

_____-_____-________

  1. Fax

_____-_____-________

  1. Email


  1. Practice Name and Address






Specialist #2

  1. Specialist Full Name



  1. Specialty

(select one)

Oncologist Neurologist

Psychologist Psychiatrist

Cardiologist Ophthalmologist/Optometrist

OBGYN

Other _______________________

  1. Phone

_____-_____-________

  1. Fax

_____-_____-________

  1. Email


  1. Address













Specialist #3

  1. Specialist Full Name



  1. Specialty (select one)

Oncologist Neurologist

Psychologist Psychiatrist

Cardiologist Ophthalmologist/Optometrist

OBGYN

Other _______________________

  1. Phone

_____-_____-________

  1. Fax

_____-_____-________

  1. Email


  1. Practice Name and Address


  1. Clinician and Specialist Notes:












  1. Was the Clinician section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

General Health Assessment

Annual Exams, Hospitals, and Surgery

  1. How do you rate your health?

Excellent Very Good Good

Fair Poor Unknown

  1. Do you have routine annual exams?

Yes No Unknown

  1. When was your last annual exam, if known?


  1. Have you had surgery in the past 10 years?

Yes No Unknown

  1. List all surgical procedures in the past 10 years




Specific Health Questions

  1. Do you use an assistive device to help you move?

Yes No

  1. Select all assistive device(s) that apply

Cane Motorized Scooter

Walker Wheelchair

  1. Do you need assistance obtaining any of the following (select all that apply)?

Eyeglasses Hearing aids

Dentures None

Other

  1. Does you take care of your own feet/toenails?

Yes No

  1. If you do not take care of your own feet/toenails, who does?


  1. Do you have any foot conditions (select all that apply)

Calluses Corns

Cuts Bruises

Fungus Overgrown Toenails

Ingrown Toenails Dry Skin

N/A Other

  1. How many days a week do you get a total of 30 minutes or more of physical activity? (enough to raise breathing rate) (select one)

Zero One

Two Three

Four Five

Six Seven

  1. Was the General Health Assessment section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions







Diagnosis

Diagnosis (select all that apply)

Notes

  1. Heart/ Circulation

  • Cancer

  • Anemia

  • Atrial Fibrillation or other Dysrhythmias (bradycardias and tachycardia)

  • Coronary Artery Disease (angina, myocardial infarction, atherosclerotic heart disease)

  • Deep Vein Thrombosis

  • Pulmonary Embolus

  • Pulmonary Edema

  • Peripheral Vascular Disease

  • Heart Disease

  • Pre-Hypertension

  • Hypertension

  • Pacemaker/ Implantable Cardiac Defibrillator


  1. Gastrointestinal

  • Cirrhosis

  • Ulcer (esophageal, gastric, and peptic ulcers)

  • GERD or Acid Reflux

  • Diverticulitis

  • Liver Disease

  • Crohn’s Disease

  • Irritable Bowel Syndrome





  1. Genitourinary

  • Benign Prostatic Hyperplasia

  • Renal Insufficiency

  • Renal Failure

  • End Stage Renal Disease

  • Neurological Bladder

  • Obstructive Uropathy


  1. Infections

  • Multi-drug resistant organisms

  • Pneumonia

  • Septicemia

  • Tuberculosis

  • Urinary Tract Infection

  • Viral Hepatitis

  • Wound Infection (other than foot)


  1. Metabolic and Endocrine

  • Diabetes Mellitus

  • Pre-Diabetes

  • Hyponatremia

  • Hyperkalemia

  • Hyperlipidemia

  • Thyroid Disease


  1. Musculoskeletal

  • Arthritis

  • Osteoporosis

  • Hip Fracture

  • Other Fracture


  1. Neurological

  • Alzheimer’s Disease

  • Aphasia

  • Cerebral Palsy

  • Cerebrovascular Accident

  • Transient Ischemic Attack

  • Stroke

  • Non-Alzheimer’s Dementia

  • Hemiplegia

  • Hemiparesis

  • Paraplegia

  • Quadriplegia

  • Multiple Sclerosis

  • Huntington’s Disease

  • Parkinson’s Disease

  • Tourette’s Syndrome

  • Seizure Disorder

  • Epilepsy

  • Traumatic Brain Injury


  1. Nutritional

  • Malnutrition

  • Risk for Malnutrition


  1. Psychiatric Mood Disorders

  • Anxiety Disorder

  • Depression

  • Manic Depression (bipolar)

  • Psychotic Disorder

  • Schizophrenia

  • Post-Traumatic Stress Disorder


  1. Addiction

  • Nicotine

  • Alcohol Abuse


  1. Sleep Disorder

  • Insomnia

  • Sleep Apnea


  1. Pulmonary

  • Asthma

  • Chronic Obstructive Pulmonary Disorder

  • Chronic Lung Disease (chronic bronchitis and restrictive lung diseases such as asbestosis)

  • Respiratory Failure


  1. Hearing

  • Hearing Impairment


  1. Vision

  • Cataracts

  • Glaucoma

  • Macular Degeneration

  • General Visual Decline


  1. Other

  • Chronic Pain

  • Obesity

  • Other


  1. Was the Diagnosis section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



Medication

Medication Name

Strength (i.e. dosage)

Units

Dosage Frequency

Dosage Number

Dosage Method

Special Instructions



























































































  1. Was the Medication section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

Medication Review

Medication #1 (enter name of medication): __________________________

  1. Medication Review Prescription Status (select all that apply)

New taken < 1 week

Ongoing

Review requested

Discontinued

Prescription not filled

Refill overdue

Other

  1. Why are you taking this medication?


  1. Does the participant seem to understand why they are taking this medication?

Yes No N/A

  1. Are you able to read the prescription label?

Yes No N/A

  1. How do you take this medication? (select all that apply)

Self (i.e., the participant)

Caregiver

RN

Unknown

Other

  1. Where do you store this medication? (select one)

Bag

Bathroom cabinet

Refrigerator

Bathroom counter

Box

Kitchen cabinet

Kitchen counter

Mixed containers

Multiple locations

Night stand

Other

  1. Would you like to consider an alternative medication, if available? (select one)

Yes

No

N/A

  1. Would you like to speak with your doctor or pharmacist about this medication? (select one)

Yes

No

N/A

  1. Does this participant share their medication with anyone? (select one)

Yes

No

N/A

  1. After reviewing all of this participant’s medications, is an additional medication review or medication reconciliation recommended? (select one)

Yes

No

N/A

Medication #2 (enter name of medication): __________________________

  1. Medication Review Prescription Status (select all that apply)

New taken < 1 week

Ongoing

Review requested

Discontinued

Prescription not filled

Refill overdue

Other

  1. Why are you taking this medication?


  1. Does this participant seem to understand why they are taking this medication?

Yes

No

N/A

  1. Are you able to read the prescription label?

Yes

No

N/A

  1. How do you take this medication? (select all that apply)

Self (i.e., the participant)

Caregiver

RN

Unknown

Other

  1. Where do you store this medication? (select one)

Bag

Bathroom cabinet

Refrigerator

Bathroom counter

Box

Kitchen cabinet

Kitchen counter

Mixed containers

Multiple locations

Night stand

Other

  1. Would this participant like to consider an alternative medication if available? (select one)

Yes

No

N/A

  1. Would this participant like to speak with the prescribing clinician or pharmacist about this medication? (select one)

Yes

No

N/A

  1. Does this participant share their medication with anyone? (select one)

Yes

No

N/A

  1. After reviewing all of this participant’s medications, is an additional medication review or medication reconciliation recommended? (select one)

Yes

No

N/A

  1. Was the Medication Review section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



Supplemental Mediation Review sheets are available at the end of this Assessment for printing when necessary.












Morisky 8-Item Medication Adherence Questionnaire

Question

Patient Answer

  1. Do you sometimes forget to take your medicine?

Yes

No

  1. People sometimes miss taking their medicines for reasons other than forgetting. Thinking over the past two weeks, were there any days when you did not take your medicine?

Yes

No

  1. Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it?

Yes

No

  1. When you travel or leave home, do you sometimes forget to bring along your medicine?

Yes

No

  1. Did you take all your medicines yesterday?

Yes

No

  1. When you feel like your symptoms are under control, do you sometimes stop taking your medicine?

Yes

No

  1. Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan?

Yes

No

  1. How often do you have difficulty remembering to take all your medicine?

Never/rarely

Once in a while

Sometimes

Usually

All the time

  1. Was the Morisky Medication Adherence section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions













































Allergies

  1. Allergy Name(s) (specify all allergies):




  1. Allergy Notes (specify for all allergies):




  1. Intolerance Name (specify for all allergies):




  1. Intolerance Notes (specify for all allergies):




  1. Was the Allergies section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



Vitals

  1. Blood Pressure Sitting (systolic/diastolic)


  1. Heart Rate


  1. Weight (lbs.)


  1. Height (inches)


  1. BMI (calculated automatically)


  1. Temperature


  1. Pain (indicate zero to 10, with zero being no pain and 10 being the most intense pain)


  1. A1C Number


  1. Oxygen Saturation %


  1. Home Blood Glucose


  1. Edema (select one)

Absent +1 +2 +3 +4

  1. Respiratory rate


  1. Vitals Notes:












  1. Was the Vitals section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

Physical Self-Maintenance Scale (PSMS): Activities of Daily Living (ADLs)

  1. Toileting Hygiene

Independent Needs Assistance

  1. Feeding or Eating

Independent Needs Assistance

  1. Dressing Upper Body

Independent Needs Assistance

  1. Dressing Lower Body

Independent Needs Assistance

  1. Grooming

Independent Needs Assistance

  1. Bathing

Independent Needs Assistance

  1. Toilet Transferring

Independent Needs Assistance

  1. Transferring

Independent Needs Assistance

  1. Ambulation/Locomotion

Independent Needs Assistance

  1. Was the PSMS/ADLs section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



















Instrumental Activities of Daily Living (IADLs)

  1. Telephone

Independent Needs Assistance

  1. Traveling

Independent Needs Assistance

  1. Shopping

Independent Needs Assistance

  1. Preparing Meals

Independent Needs Assistance

  1. Housework

Independent Needs Assistance

  1. Medications

Independent Needs Assistance

  1. Money

Independent Needs Assistance

  1. Was the IADLs section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

























Nutrition Screen (DETERMINE)

These questions identify older persons at risk for low nutrient intake and subsequent health problems. Communicate to participant: “What you eat does affect your health. These questions help us determine any if you are at nutritional risk.”

Summing the scores associated with each Yes answer indicates:

  • Low nutritional risk = score 0-2

  • Moderate nutritional risk = score 3-5

  • High nutritional risk = score 6 or more

  1. Have you made any changes in lifelong eating habits because of health problems?

Yes (2) No (0)

  1. Do you eat fewer than two meals a day?

Yes (3) No (0)

  1. Do you eat fewer than five servings (1/2 cup each) of fruits and vegetables every day?

Yes (1) No (0)

  1. Do you eat fewer than two servings of dairy products (such as milk, yogurt, or cheese) every day?

Yes (1) No (0)

  1. Do you sometimes not have enough money to buy food?

Yes (4) No (0)

  1. Do you have trouble eating due to problems with biting, chewing, or swallowing?

Yes (2) No (0)

  1. Do you eat alone most of the time?

Yes (1) No (0)

  1. Without wanting to, have you lost or gained ten pounds in the last six months?

Yes (2) No (0)

  1. Are you not always physically able to shop, cook, and/or feed yourself (or get someone to do it for you?)

Yes (2) No (0)

  1. Do you have three or more drinks of beer, liquor, or wine almost every day?

Yes (2) No (0)

  1. Do you take three or more prescriptions or over-the-counter drugs per day?

Yes (1) No (0)

Total Score:


  1. Was the Nutrition Assessment section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

































Falls Risk Assessment (STEADI)

These questions identify persons at risk for falling.

Sum the scores associated with each “Yes” answer. Scores of 4 points or more indicate the participant may be at risk for falling.

Question

Why it matters

Answer

  1. I have fallen in the past year.

People who have fallen once are likely to fall again.

Yes (2) No (0)

  1. I use or have been advised to use a cane or walker to get around safely.

People who have been advised to use a cane or walker may already be more likely to fall.

Yes (2) No (0)

  1. Sometimes I feel unsteady when I am walking.

Unsteadiness or needing support while walking are signs of poor balance.

Yes (1) No (0)

  1. I steady myself by holding onto furniture when walking at home.

This is also a sign of poor balance.

Yes (1) No (0)

  1. I am worried about falling.

People who are worried about falling are more likely to fall.

Yes (1) No (0)

  1. I need to push with my hands to stand up from a chair.

This is a sign of weak leg muscles, a major reason for falling.

Yes (1) No (0)

  1. I have some trouble stepping up onto a curb.

This is also a sign of weak leg muscles.

Yes (1) No (0)

  1. I often have to rush to the toilet.

Rushing to the bathroom, especially at night, increases your chance of falling.

Yes (1) No (0)

  1. I have lost some feeling in my feet.

Numbness in your feet can cause stumbles and lead to falls.

Yes (1) No (0)

  1. I take medicine that sometimes make some feel lightheaded or more tired than usual.

Side effects from medicines can sometimes increase you a chance of falling.

Yes (1) No (0)

  1. I take medicine to help me sleep or improve my mood.

These medicines can sometimes increase your chance of falling.

Yes (1) No (0)

Total Score:


  1. Was the Falls Risk Assessment section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions
























Mini Cog

Begin the cognitive assessment with word recall.



Have the participant repeat the following three words right after you say them: Telephone, umbrella, flowers.

This is to make sure they heard and understood the words correctly.



Next, provide a blank piece of paper to the participant and ask them to do the following steps:

  • First, draw the face of a clock and put all of the numbers on it. Make it large.

  • Now, draw the hands, point at 20 minutes before 4 O’clock, Good.



Keep the clock drawing.



Ask the participant, “Please tell me the three words I asked you to remember earlier.” Note how many words the participant was able to recall.



Next, is the category fluency, please make sure you have a timing device available. Say, “When I tell you to start, please name as many kinds of animals as you can think of in one minute. Ok?” When the person is ready. Say, “begin” and start the timer. At the end of 60 seconds stop the timer and say, “Ok, that’s good. Thank you.” Keep track of how many animals they named here (which animal is not important).






  1. Clock Drawing

5-7 points = passing score

4 points = borderline

0-3 points = failing score

  1. Three Word Recall (1 point for each word correctly recalled)

3 points = passing score

2 points = borderline

1-0 points = failing score

  1. Category Fluency

>15 animals

named within

the one minute = passing score

15 animals = borderline

<15 animals = failing score

  1. Total Cognitive Ability Score: Pass/Fail (Fail if: fail 2 or more components OR scores “borderline” on 2 of 3 components)

Pass Fail

  1. Participant is unable to perform the cognitive screen

Yes No

  1. Additional information about cognitive assessment:






  1. Was the Mini Cog section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions













Use this page for the Mini Cog:





































Use this page for the Mini Cog:



































Loneliness Scale

The scores of each individual question can be added together to give range of scores from 3 to 9. Researchers have grouped people who score 3-5 as “not lonely” and people with a score of 6-9 as “lonely.”

  1. How often do you feel that you lack companionship?

Hardly ever (1) Some of the time (2)

Often (3) Not performed

  1. How often do you feel left out?

Hardly ever (1) Some of the time (2)

Often (3) Not performed

  1. How often do you feel isolated from others?

Hardly ever (1) Some of the time (2)

Often (3) Not performed

  1. Was the Social Connectedness section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions











Behavioral Health

  1. How many times in the past year have you had four or more alcoholic drinks in a day? (select one)

Zero One Two

Three or more times

If answer above is “Two” or “Three or more,” complete the S-MAST-G below.

  1. What is your current relationship with tobacco (select one)?

Never

Former

Current tobacco user

Currently exposed to second hand smoke

No for medical reasons

  1. Would you like assistance with tobacco cessation?

Yes No Not now

N/A

  1. Notes:


  1. Was the Behavioral Health section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions



S-MAST-G


Two or more “Yes” answers below indicate the need for a brief intervention and possibly a referral for assessment and treatment.

  1. When talking to others, do you ever understate how much you actually drink?

Yes No

  1. When drinking, have you sometimes skipped a meal because you did not feel hungry?

Yes No

  1. Does having a few drinks help reduce shakiness or tremors?

Yes No

  1. Does alcohol sometimes make it hard for you to remember parts of a day or night?

Yes No

  1. Do you usually take a drink to relax or calm your nerves?

Yes No

  1. Do you drink to take your mind off problems like feeling alone or being in physical or emotional pain?

Yes No

  1. Have you increased your drinking after experiencing a loss in your life?

Yes No

  1. Has a doctor, nurse, or other health care provider ever said that they were concerned about your drinking?

Yes No

  1. Have you tried to reduce your drinking from your own concern or to try and manage the amount of your drinking?

Yes No

  1. When you feel lonely does having a drink help you feel better?

Yes No

  1. Do you drink alcohol and at the same time use mood or mind altering drugs, including prescription, tranquilizers, prescription sleeping pills, prescription pain pills, or illicit drugs?

Yes No

  1. Notes:






















  1. Was the S-MAST-G section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

Not applicable











General Anxiety Disorder Scale (GAD-2)

  1. Over the past two weeks, how often have you been bothered by feeling nervous, anxious, or on edge (circle one)?

0 – Not at all

1 – Several days

2 – more than half the days

3 – Nearly every day

  1. Over the past two weeks how often have you been bothered not being able to stop or control worrying (circle one)?

0 – Not at all

1 – Several days

2 – more than half the days

3 – Nearly every day

Total Score:


If the total score from two GAD-2 questions above is 3 or higher, complete GAD-7 below.



General Anxiety Disorder Scale (GAD-7)

Scoring: Sum points from all GAD-7 answers: 5-9 Mild Anxiety, 10-14 Moderate Anxiety, 15 + Severe Anxiety

  1. Over the last two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. Over the last two weeks, how often have you been bothered by not being able to stop or control worrying

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. Over the last two weeks, how often have you been worrying too much about different things

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. Over the last two weeks, how often have you had trouble relaxing

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. Being so restless that it is hard to sit still

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. Becoming easily annoyed or irritable

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. Feeling afraid as if something awful might happen

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Total Score:


  1. Was the GAD-7 section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

Not applicable



Patient Health Question-2 (PHQ-2): Depression Screener

  1. Over the past two weeks, how often have you been had little interest or pleasure in doing things

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

  1. Over the past two weeks, how often have you felt down, depressed, or hopeless

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day

Total Score:


If the total PHQ-2 score is 3 or greater complete the PHQ-9


  1. Was the PHQ-2 section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions


Patient Health Question-9 (PHQ-9)

For participants who scored 3 or greater total points on the PHQ-2 complete this section. .


Ask the participant: “Over the past two weeks, how often have you been bothered by any of the following problems?


  1. Over the past two weeks, how often have you had trouble falling asleep, staying asleep, or sleeping too much

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day


  1. Over the past two weeks, how often have you felt tired or had little energy

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day


  1. Over the past two weeks, how often have you been bothered by poor appetite or overeating

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day


  1. Over the past two weeks, how often have you been bothered by feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day


  1. Over the past two weeks, how often have you been bothered by trouble concentrating on things such as reading the newspaper or watching television

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day


  1. Over the past two weeks, how often have you been bothered by moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that you have been moving around a lot more than usual.

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day


  1. Over the past two weeks, how often have you been bothered by thinking that you would be better off dead or that you want to hurt yourself in some way

0-Not at all

1-Several Days

2-Over Half of the Days

3-Nearly Every Day


Total Score:



Take the total score from PHQ-2 and add to the sum of the additional questions.

0-4 = minimal depression, 5-9 = mild, 10-14 = moderate, 15-19 = moderately severe, 20-27 = severe.


  1. Was the PHQ-9 section completed in full?

Yes – section completed in full

No – not yet completed

No – participant refused to answer one or more questions

Not applicable





Assessment Status


  1. If the IWISH health and wellness assessment was not completed in full, please indicate the reason(s) why. (select all that apply)

Participant declined to complete one or more sections

Participant did not respond to at least three attempts to contact

Participant already has completed an assessment with another program

Other reason







Supplemental Medication Review

Medication (enter name of medication): __________________________

  1. Medication Review Prescription Status (select all that apply)

New taken < 1 week

Ongoing

Review requested

Discontinued

Prescription not filled

Refill overdue

Other

  1. Why are you taking this medication?


  1. Does the participant seem to understand why they are taking this medication?

Yes No N/A

  1. Are you able to read the prescription label?

Yes No N/A

  1. How do you take this medication? (select all that apply)

Self (i.e., the participant)

Caregiver

RN

Unknown

Other

  1. Where do you store this medication? (select one)

Bag

Bathroom cabinet

Refrigerator

Bathroom counter

Box

Kitchen cabinet

Kitchen counter

Mixed containers

Multiple locations

Night stand

Other

  1. Would you like to consider an alternative medication, if available? (select one)

Yes

No

N/A

  1. Would you like to speak with your doctor or pharmacist about this medication? (select one)

Yes

No

N/A

  1. Does this participant share their medication with anyone? (select one)

Yes

No

N/A

  1. After reviewing all of this participant’s medications, is an additional medication review or medication reconciliation recommended? (select one)

Yes

No

N/A



3

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