CONDENSED REASSESSMENT TOOL
Assessment Date: __________ Time: ______ Nurse I.D.: ________ Policy No.: ___________
PERSONAL INFORMATION
CLAIMANT INFORMATION
Name: ____________________________________________________________________
Street Address: _____________________________________________________________
City: ___________________________________________ State:_______ Zip:__________
Telephone: (____) _______________________
Please ask for government picture identification
Date of Birth ___________ Sex:
M
F
Other than insured, who is present at assessment?
Name ____________________________
Relationship_____________________
Name ____________________________
Relationship ____________________
CONTACT INFORMATION
Name: __________________________________
Relationship_____________________
Mailing Address: ____________________________________________________________
Telephone: (____) _____________________
Is this person present at the assessment? Yes
No
Relationship to Insured: _________________________________________
Does this person hold POA? Yes
No
If “No,” who has Power of Attorney? ___________________________________________
Address: _________________________________________________________________
Telephone: _______________________________________________________________
There is no Power of Attorney
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
CURRENT LIVING ARRANGEMENTS
Does client live alone? Yes
No
If “Yes,” who lives with the Insured?
Name _______________________________ Relationship _______________________________
Name _______________________________ Relationship _______________________________
Place of Assessment:
Private home
If a private home, is it:
Your own home
Assisted Living
Skilled Facility
Assisted Living
Skilled Facility
Other:
The home of another individual
Other:_____________________________________________
Name of facility? ______________________________________admit date:_______________________
Reason Admitted?_____________________________________________________________________
Address (if different from above):_____________________________________________________
Phone (include area code)________________________ Fax: _________________________________
If in a facility, please obtain a copy of Current License and MDS / Nursing Assessment
Insureds location before admit to facility: ___________________________________________________
Do you have a discharge date?
No
If no: Date of discharge unknown
Plans to stay long term
Yes
If yes: Anticipated date of discharge: _________________
When were you last living at home? _______________________________________________________
Is the bed state licensed? (NOT necessarily Medicare licensed)
Yes
No
How is the insured’s bed specifically licensed?
Nursing home
Assisted Living Facility
Dementia Unit
Other (be specific): ______________________________________________________________
If the insured is on a Dementia Unit, is it secured?
Unsecured
Door Alarms Only
Secured (describe): ______________________________________________________________
Can the insured leave the facility unattended?
Yes
No
Name of person who gave you above information: ____________________________________________
Administrator
DON
LTC Claims Advisory Committee Guide 2007
Other (describe) ___________________________________
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CONDENSED REASSESSMENT TOOL
MEDICAL HISTORY
MEDICAL INFORMATION:
Have there been any changes in the insured’s medical history since the last care needs
Yes
No If “Yes,” please collect the following information:
assessment?
How has the insured’s condition changed? _________________________________________________
On what date did that change occur? ______________________________________________________
If the insured was previously receiving home care assistance, did the amount of assistance increase?
Yes
No If “Yes,” please describe the changes made in the level of home care assistance.
____________________________________________________________________________________
Are family members assisting with care?
Yes
No If “Yes,”:
a. What type of assistance is being provided? _______________________________________
b. What is the frequency of the assistance provided? __________________________________
Information received from: ___ Insured ___ Family Member ___Chart ___ Other___________________
List any new physicians the insured has seen since the last care needs assessment:
Physician’s Name: ______________________________________Specialty:_______________________
Address: ____________________________________________________________________________
Phone: _____________________ Date of last visit: ______________ Reason: _____________________
Physician’s Name: ______________________________________Specialty:_______________________
Address: ____________________________________________________________________________
Phone: _____________________ Date of last visit: ______________ Reason: _____________________
List any hospitalizations which have occurred since the last care needs assessment:
Name of hospital: ________________________________________Dates:________________________
City and state of hospital: _______________________________________________________________
Reason for admission: _________________________________________________________________
Name of hospital: ________________________________________Dates:________________________
City and state of hospital: _______________________________________________________________
Reason for admission: _________________________________________________________________
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
MEDICATION LIST (list all current medications)
Ask insured to show all of their prescription bottles and containers as well as
over-the-counter medications, vitamins, and supplements that they currently use.
If insured is in a facility, you may attach a copy of their current medication list. If
there are any medications for which there was no diagnosis listed, update the
diagnosis list.
Medication
Reason
Dosage
Prescribing
Physician
Frequency
Medication Administration:
Independent
Requires Supervision
Requires Limited Assistance
Requires Total Assistance
HEALTH
Does insured currently use oxygen?
Continuous
Yes
No If “Yes,” check the appropriate box:
At night only
Other: ____________________________________
Has insured lost more than 10 pounds in the last six months without trying?
If “Yes,” how many pounds? ________ lbs.
Yes
No
No
Does Insured follow a special diet or take nutritional supplements (e.g. ensure) Yes
If “Yes,” what type? ____________________________________________________________________
No
Does insured have paralysis in any part of body? Yes
R arm
R leg
L arm
L leg
If “Yes,” check all that apply:
Other (describe) ___________________________________________
Has insured had an amputation of any type? Yes
No
R arm
R leg
L arm
L leg
If “Yes,” check all that apply:
Other (describe) ___________________________________________
Does insured have a prosthesis?
Yes
No
If “Yes,” what kind? ___________________________
No
Is insured wearing a cast? Yes
If “Yes” a. Reason: ___________________________________________________________
b. Duration: ___________________________________________________________
c. Location: ____________________________________________________________
No
Does the insured have any type of open wound or sore on their body? Yes
If “Yes” a. Type of wound/sore: _____________________________________________________
b. Location: ______________________________________________________________
No
c. Is it being treated? Yes
d. Describe treatment: ______________________________________________________
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CONDENSED REASSESSMENT TOOL
Does the insured have any pain? Yes
No
If “Yes” a. Where is the pain? ___________________________________________________________
b. What is the severity? (on a scale from 1 to 10, 1= least & 10 = most severe): ______________
c. How often does it occur? _______________________________________________________
d. What causes the pain?
_____________________________________________________
e. What relieves the pain? _______________________________________________________
f. What make the pain worse? ____________________________________________________
Has the Insured received Physical Therapy or Occupational Therapy within the past 90 days?
Yes
No
If “Yes” a. Date(s): ___________________________________________________________________
b. Reason: ____________________________________________________________________
c. Location:
Home
Outpatient
Rehab Facility
Hospital
No
Does the insured currently perform any type of exercise? Yes
If ”Yes,” please describe: _______________________________________________________________
No
Have there been other medical problems since the last care needs assessment? Yes
If “Yes,” please describe: _______________________________________________________________
Is the insured bed bound?
Yes
No
Can the insured follow simple directions?
Yes
No
No
Has the insured tripped or fallen in the past year? Yes
If “Yes” a. Number of falls: ______________
b. Dates: __________________________________
c. Reason for fall(s)? _________________________________________________________
d. Was the physician notified? __________________________________________________
If the insured has fallen in the past year please complete the Fall Risk
Assessment.
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
ADL ASSESSMENT INSTRUCTIONS
Activities of Daily Living
Complete as it pertains to all functions noted by observing the insured. Examples of such observations
are noted below under Considerations in Performing Assessment. Please note that while this assessment
tool is similar to the OASIS, it is not the same. Please read each section carefully and mark the most
appropriate response.
Considerations in Performing an Assessment:
Prior to assessing range of motion (ROM), a visual observation of the bathroom must be performed to
determine actual range of motion required based on the individual’s bathroom facilities, e.g., toilet riser,
grab bars, walk-in shower versus step-up tub.
Ask the insured to ambulate to the bathroom to show you how they would perform toileting, getting in and
out of a seated position, reaching, range of motion, and balance. Document observations of the insured
getting in and out of a seated position, reaching, upper/lower extremity strength, fine motor skills, ROM,
balance.
Ask the insured to show you how they handle the supplies or equipment and related hygiene. Document
observations of the insured managing continence such as strength, fine motor skills, ROM, balance.
Also, document appropriate use of assistive devices.
Ask the insured to show you how they would bathe, and observe ROM, balance, reaching back and feet,
drying body off. Document observations of insured’s upper/lower extremity strength, fine motor skills,
ROM, balance, reaching.
Ask the insured to put on a sweater or shirt. Document observations of insured’s upper extremity
strength, fine motor skills, ROM, balance. Document what type of assistive devices might help the
insured complete the task, such as a device for buttoning.
Definitions to consider:
Verbal cueing: Unable to initiate or complete task without verbal instructions
Stand-by assistance: Requires the presence of another person within arm’s reach for contact guard to
prevent injury by physical intervention to complete the task if needed.
Hands-on assistance: Requires physical assistance from another person to perform the activity.
NOTE
Send the completed assessment directly to the requesting company. DO NOT provide any part
of the assessment to the insured. If the insured or their legal representative requests a copy of
the assessment or any portion of the assessment, instruct them to put their request in writing to
their long term care insurance company.
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
ADL ASSESSEMENT
FUNCTIONAL ASSESSMENT
Check the box that most accurately describes the level of assistance required. Provide a brief narrative
of insured’s deficits. Ask to see insured demonstrate whenever possible.
1. Eating: The ability to feed self meals and snacks. Note: This refers only to the process of
eating, chewing, and swallowing. It does not include meal prep or getting food to the table.
Observed
Uses adaptive equipment?
Yes
Interviewed
No Type: ___________________________________________
Able to independently feed self
Able to feed self independently but requires intermittent verbal cuing from another person
Able to feed self independently but requires stand-by assistance due to swallowing difficulties or
choking risk
Unable to feed self and requires hands-on assistance throughout the meal/snack
Able to take in nutrients orally and receives supplemental nutrients through a nasogastric tube or
gastrostomy
Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy
Unable to take in nutrients orally or by tube feeding
Explanation/Examples: _________________________________________________________________
____________________________________________________________________________________
Please check when assistance is required:
Morning
Afternoon
Evening
Snacks
Would any assistive devices, not already in place, increase the insured’s independence with eating?
Yes
No If “Yes,” please indicate the type of device(s) deemed appropriate to increase
independence: _______________________________________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
2. DRESSING: Putting on and taking off all items of clothing and any necessary braces, fasteners,
or artificial limbs, and selecting clean, weather-appropriate clothing
Observed
Uses adaptive equipment?
Yes
Interviewed
No Type: ___________________________________________
Ability to Dress Upper Body (with or without dressing aids) including undergarments, pull-overs, frontopening shirts and blouses, managing zippers, buttons, and snaps:
Able to get clothes out of closets and drawers, put them on, and remove them from the upper body
without assistance
Able to dress self but requires another person to get them out and set them within arms reach
Able to dress upper body but requires verbal cueing to complete process
Someone must stand by to help the patient put on upper body clothing
Requires hands-on assistance from another person to dress the upper body
Ability to Dress Lower Body (with or without dressing aids) including undergarments, slacks, socks or
nylons, shoes:
Able to obtain, put on, and remove clothing and shoes without assistance
Able to dress self but requires another person to get them out and set them within arms reach
Able to dress lower body but requires verbal cueing to complete process
Someone must stand by the patient to put on undergarments, slacks, socks or nylons, and shoes
Requires hands-on assistance from another person to dress lower body
Explanation/Examples: _________________________________________________________________
____________________________________________________________________________________
Length of time to fully dress:
less than 15 min.
15 - 30 min.
30 – 45 min.
> 45 min.
How often is assistance provided? No. of times per day:__________; No. of times per week:_________
Who provides assistance? ______________________________________________________________
Would any assistive device, not already in place, increase the insured’s independence in dressing?
Yes
No If “Yes,” please indicate the type of device(s) deemed appropriate to increase
independence: _______________________________________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
3. Transferring: The ability to move from bed to chair, on and off toilet or commode, into and out
of tub or shower, and in and out of wheelchair.
Observed
Uses adaptive equipment?
Yes
Interviewed
No Type: ___________________________________________
Able to independently transfer
Transfers independently with use of an assistive device
Someone must stand by the patient to transfer between stationary items
Unable to transfer self but is able to bear weight and pivot during the transfer process with verbal
cueing
Unable to transfer self and requires hands-on assistance from another person to be transferred
between stationary items
Explanation/Examples: ________________________________________________________________
____________________________________________________________________________________
Who provides assistance? ______________________________________________________________
How often is assistance provided? No. of times per day: _________; No. of days per week: __________
Would any assistive devices, not already in place, increase the insured’s independence with transfers?
Yes
No If “Yes,” please indicate the type of device(s) deemed appropriate to increase
independence: _______________________________________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
9
CONDENSED REASSESSMENT TOOL
4. Mobility/Ambulation: The ability to walk or move from one place to another once in a standing
position, with or without the use of a cane or walker, or with the use of a wheelchair, once in a
seated position, on a variety of surfaces. (Please have the policyholder demonstrate ambulation to
and from the bathroom or bedroom.)
Observed
Uses adaptive equipment?
Yes
Interviewed
No Type: ___________________________________________
Able to independently walk on even and uneven surfaces with or without assistive devices
Able to independently climb stairs with or without assistive devices
Requires use of a device (e.g., cane, walker) to walk alone
Requires verbal cueing to negotiate stairs or steps or uneven surfaces
Able to walk only with stand-by assistance from another person
Chair-fast, unable to ambulate but is able to wheel self independently
Unable to ambulate and requires hands-on assistance for all mobility
Explanation/Examples: _________________________________________________________________
____________________________________________________________________________________
Who provides assistance? ______________________________________________________________
How often is assistance provided? No. of times per day: __________; No. of days per week: _________
Would any assistive devices, not already in place, increase the insured’s independence with transfers?
Yes
No If “Yes,” please indicate the type of device(s) deemed appropriate to increase
independence: _______________________________________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
5. TOILETING: Able to get to and from toilet or commode, get on and off toilet or commode, and
maintain satisfactory personal hygiene. It does not include the need or use of assistive devices or
adaptive equipment. (Ask the insured to walk to the bathroom and demonstrate ability to sit/stand
from toilet.)
Observed
Uses adaptive equipment?
Yes
Interviewed
No Type: ___________________________________________
Able to get to and from the toilet independently with or without a device
With verbal cueing by another person is able to get to and from the toilet
Able to get to and from the toilet with stand-by assistance from another
Unable to get to and from the toilet but is able to use a bedside commode, bedpan or urinal
independently
Requires hands-on assistance from another person with all toileting
Explanation/Examples: _________________________________________________________________
____________________________________________________________________________________
Who provides toileting assistance? _______________________________________________________
How often is assistance provided? No. of times per day: __________; No. of days per week: _________
Does hygiene appear adequate?
Unusual odors noted?
Yes
Yes
No
No
If “Yes,” please explain: _________________________________
Would any assistive devices, not already in place, increase the insured’s independence with toileting?
Yes
No If “Yes, please indicate the type of device(s) deemed appropriate to increase
independence: _______________________________________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
11
CONDENSED REASSESSMENT TOOL
6. Continence: Ability to voluntarily control bowel and bladder function without the aid of
another person or use an external catheter or other equipment to otherwise maintain a
reasonable level of personal hygiene. It does not include the need or use of assistive
devices or adaptive equipment.
Observed
Uses adaptive equipment?
Yes
Interviewed
No Type: ___________________________________________
Bladder:
Do you experience any loss of control of your urine?
Yes
No
If yes, when did incontinence begin? ______________ Any treatments? __________________________
Is there a noticeable urine odor due to the bladder incontinence?
Yes
No
If incontinent, is assistance required with personal hygiene related to the loss of control?
Yes
No
Who provides continence assistance? _____________________________________________________
How often does the insured experience bladder incontinence?
No. of times per day: __________; No. of days per week: _________
Does hygiene appear adequate?
Yes
No
Explanation/Examples: _________________________________________________________________
____________________________________________________________________________________
Would any assistive devices, not already in place, increase the insured’s independence with bladder
continence?
Yes
No If “Yes,” please indicate the type of device(s) deemed appropriate to
increase independence: ________________________________________________________________
____________________________________________________________________________________
Bowel:
Do you experience any loss of control of your bowels?
Yes
No
If yes, when did incontinence begin? ______________ Any treatments? __________________________
Is there a noticeable bowel odor due to the bowel incontinence?
Yes
No
If incontinent, is assistance required with personal hygiene related to the loss of control?
Yes
No
Who provides continence assistance? _____________________________________________________
How often does the insured experience bowel incontinence?
No. of times per day: __________; No. of days per week: _________
Does hygiene appear adequate?
LTC Claims Advisory Committee Guide 2007
Yes
No
12
CONDENSED REASSESSMENT TOOL
Explanation/Examples: _________________________________________________________________
____________________________________________________________________________________
Would any assistive devices, not already in place, increase the insured independence with bowel
continence?
Yes
No If yes, please indicate the type of device(s) deemed appropriate to increase
independence: _______________________________________________________________________
____________________________________________________________________________________
Durable Medical Equipment (DME):
Do you use any durable medical supplies like catheters or ostomy bags?
Yes
No
If “Yes,” type of equipment/devices: _______________________________________________________
How long have you had the equipment/devices? _____________________________________________
Do you require assistance managing your equipment/devices?
Yes
No
Would any assistive equipment/devices, not already in place, increase the insured’s independence with
bowel or bladder continence?
Yes
No If yes, please indicate the type of equipment/devices
deemed appropriate to increase independence: _____________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
13
CONDENSED REASSESSMENT TOOL
7. Bathing: Ability to get in and out of a tub or shower, ability to effectively wash self in a tub,
shower, or by sponge bath, and the process of drying off with or without the aid of another
person.
Assess insured’s ability to perform each type of bathing, completing all areas
noted.
Sponge Bath:
Observed
Uses adaptive equipment?
Interviewed
Yes
No Type: ___________________________________________
Able to physically bathe self independently
With the use of devices, is able to sponge bathe independently
Able to sponge bathe with the assistance of another person (check applicable options):
with verbal cueing to complete sponge bath
for washing difficult to reach areas
Participates in bathing self in sponge bath but requires stand-by assistance from another person
throughout the bath
Unable to participate in bathing and requires hands-on assistance from another person for the
bathing process
Tub:
Observed
Interviewed
Uses adaptive equipment?
Yes
No Type: ___________________________________________
Able to physically bathe self independently
With the use of devices, is able to bathe self in tub independently
Able to bathe in tub with the assistance of another person (check applicable options):
with verbal cueing to complete bath
to get in and out of the tub
for washing difficult to reach areas
Participates in bathing self in tub but requires stand-by assistance from another person throughout
the bath
Unable to participate in bathing and requires hands-on assistance from another person for the
bathing process
Shower:
Observed
Interviewed
Uses adaptive equipment?
Yes
No Type: ___________________________________________
Able to physically bathe self independently in the shower
With the use of devices is able to bathe self in shower independently
Able to bathe in shower with the assistance of another person (check applicable options):
with verbal cueing to complete shower
to get in and out of the shower
for washing difficult to reach areas
Participates in bathing self in shower but requires stand-by assistance from another person
throughout the shower
Unable to participate in bathing and requires hands-on assistance from another person for bathing
in the shower
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
General:
If in a facility, is it facility policy to assist with bathing?
Yes
No
Number of baths per week: ______________________________________________________________
Who provides bathing assistance? ________________________________________________________
Does hygiene appear adequate?
Unusual odors noted?
Yes
Yes
No Please explain: _______________________________
No Please explain: _______________________________________
Would any assistive devices, not already in place, increase the insured’s independence with bathing?
Yes
No If “Yes,” please indicate the type of device(s) deemed appropriate to increase
independence: _______________________________________________________________________
____________________________________________________________________________________
Additional Explanation/Examples:
____________________________________________________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
15
CONDENSED REASSESSMENT TOOL
Cognition Section
Please refer to the discussion section included in Introduction to the Condensed Reassessment
section of the LTC Claims Toolbox to learn more about utilizing cognitive testing and their
application to policy language defining benefit triggers.
This section would include the standardized test chosen by the insurance company to ascertain
the cognitive functional level of the insured. The insurer should also consider including the
scoring scheme by category (see example below) specific to the standardized test used. This will
provide a consistent application of the insurer’s administrative policy on cognitive triggers if the
assessor or a vendor will be performing tax qualified certification on behalf of the insurer.
Normal
Range
#–#
Mild
Impairment
#–#
LTC Claims Advisory Committee Guide 2007
Moderate
Impairment
#–#
Severe
Impairment
#–#
16
CONDENSED REASSESSMENT TOOL
BEHAVIORS & EMOTIONS
BEHAVIORS
“Yes” answers should only be recorded if there has been an actual occurrence of the behavior – not just
when a concern exists that it could happen. For every “Yes” answer, please give details and approximate
date of the occurrence(s) in the Comments section.
1. Have there been incidents of wandering? (Wandering is defined as incidents such as the insured
being found away from the home, moving about without rational propose, or becoming
Yes
No
permanently lost and unable to find their way home from a familiar place.)
If “Yes,” on what dates? _________________________________________________________
Please describe the incidents. _____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Yes
No If “Yes,” what is the
Have these incidents been reported to insured’s physician?
name of the physician? __________________________________________________________
2. Have there been incidents of behaviors that subject the insured to significant safety risks? (This
includes activities such as unsafe use of tools or recurring incidents such leaving gas stoves on
Yes
No If “Yes,” on what dates? ____________________________
while not cooking.)
_____________________________________________________________________________
Please describe the incidents. _____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Yes
No If “Yes,” what is the
Have these incidents been reported to insured’s physician?
name of the physician? __________________________________________________________
3. Have there been incidents that pose a significant risk to the insured’s health? (These should
generally be recurrent in nature, such as refusing to eat, refusing to follow medical treatments
without a rational reason, or going outside in clothing that is completely inappropriate for the
weather. They generally would not include using a “pill dispenser” to help take medication
properly or eating (regularly) a diet that others might view as unhealthy but not bizarre.)
Yes
No If “Yes,” on what dates? _____________________________________________
_____________________________________________________________________________
Please describe the incidents. _____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Yes
No If “Yes,” what is the
Have these incidents been reported to insured’s physician?
name of the physician? __________________________________________________________
4. Have there been incidents of abusive or violent behavior? (This generally should not include
opinions that the insured is “grumpy, angry, or cranky” without actual abusive or violent behavior.)
Yes
No If “Yes,” on what dates? _____________________________________________
_____________________________________________________________________________
Please describe the incidents. _____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
No If “Yes,” what is the
Have these incidents been reported to insured’s physician? Yes
name of the physician? __________________________________________________________
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
5. Have there been incidents of poor judgment or uncooperative behaviors that have resulted in the
No If “Yes,” on what dates?
insured being found/put at risk to harm themselves? Yes
_____________________________________________________________________________
Please describe these incidents. ___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Yes
No If “Yes,” what is the
Have these incidents been reported to insured’s physician?
name of physician? _____________________________________________________________
Comments:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EMOTIONS
Do you often feel sad or blue?
Do you enjoy life?
Yes
Yes
No
If “Yes,” how often? __________ how long? __________
No If “No,” why not? __________________________________________
Circle all that currently apply, as reported by the ___ insured ___ caregiver:
Angry
Anxious
Apathetic
Combative
Depressed
Fearful
Paranoid/Suspicious
Withdrawn
No
Is the insured unsafe alone? Yes
Explain _____________________________________________________________________________
No
Have you ever been treated for any of the above-mentioned emotional problems? Yes
If “Yes,” a. Which emotional problem: __________________________________________________
b. Dates of treatment: _______________________________________________________
c. Type of treatment: ________________________________________________________
What precipitated the above mentioned emotions? ___________________________________________
Comments: __________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
General Affect: Please circle all that apply as observed by the Assessor:
Agitated
Alert
Appropriately dressed
Cheerful
Confused
Cooperative
Disoriented
Flat affect
Lethargic
Nervous
Oriented
Pleasant
Tearful
Well groomed
Comments: __________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
LTC Claims Advisory Committee Guide 2007
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CONDENSED REASSESSMENT TOOL
IADL ASSESSMENT
Check the appropriate box concerning the insured’s ability to perform their Instrumental Activities of Daily Living
Activity
Insured is
Independent
Insured
Requires
Limited
Assistance
Insured
Requires
Total
Assistance
Insured
Requires
Supervision
Did the
insured ever
do this
activity?
If alone,
could the
insured do
this activity?
Do you
expect the
insured to do
this activity in
the future?
Meal Preparation
Yes
No
Yes
No
Yes
No
Light Meal
Preparation/Reheating
Yes
No
Yes
No
Yes
No
Heavy Housekeeping
Yes
No
Yes
No
Yes
No
Light Housekeeping
Yes
No
Yes
No
Yes
No
Laundry
Yes
No
Yes
No
Yes
No
Telephone Use
Yes
No
Yes
No
Yes
No
Personal Finances
Yes
No
Yes
No
Yes
No
Medication
Management
Yes
No
Yes
No
Yes
No
If the insured is unable to perform
this activity:
Who performs
activity now?
Did the insured ever drive? Yes
No
Yes
No Frequency: ________________________________________________________
Does the insured still drive?
No If “Yes,” by who? __________________________________
Was the insured instructed not to continue driving? Yes
How does the insured get to medical appointments? _____________________________________________________________
Additional information/comments on IADLs: ____________________________________________________________________
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19
Date Started
CONDENSED REASSESSMENT TOOL
FALL RISK ASSESSMENT
(If insured is in a facility, answers may be obtained by reviewing the chart.)
Insured Name: _____________________________________________ Date _____________________
Environment Observed: Home ___ Facility ____
Physical Factors:
Has the insured fallen in the last
30 days
31-180 days
181-365 days?
How many times has the insured fallen in the last ____ 30 days ____ 31-180 days ____ 181-365 days?
What caused the insured to fall? _________________________________________________________
Yes
Was the insured injured?
Was the insured seen by an MD?
No Describe injuries ____________________________________
Yes Date _____________
No
MD Name and Address: ________________________________________
________________________________________
No If “Yes,” please describe:_________
Are there any fall precautions in place at this time? Yes
____________________________________________________________________________________
Has the insured complained of dizziness or exhibited unsteadiness in the past 30 days?
Yes
No
Orthostatic Blood Pressures (Orthostatic pressures must be done in this order lying, sitting, standing.
Two or three minutes must elapse between each position change)
Lying: ____________
Sitting: ___________
Standing: _________
Has insured experienced an unplanned weight loss of 10 or more pounds since the last care needs
assessment?
Yes
No If “Yes,” please explain: _________________________________________
Is the insured homebound?
Yes
No If “Yes,” how long? ____________ Why?________________
Environmental Factors Contributing to Fall Risk:
Are stairs used to enter/exit?
Yes
No
Yes
Is sleeping area easily accessible to insured?
Are walk areas to rooms used in home cluttered?
Is there poor lighting in rooms or on stairs?
No
Yes
Yes
No
No
Are there electrical cords or phone cords crossing walk areas?
Are there throw rugs present with edges not anchored?
LTC Claims Advisory Committee Guide 2007
Yes
Yes
No
No
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CONDENSED REASSESSMENT TOOL
Medication Factors:
Check all that apply for each condition:
Condition
History of
Being Treated
(other then meds)
Taking Medication
Anti-Anxiety
Anti-psychotic
Anti-depressant
Anti-hypertensive
Medication Factors:
Is the insured taking any of the following (check all that apply):
Diuretic
Hypnotic
Narcotic
HOME HEALTHCARE INFORMATION
Complete this section for all providers such as PT, OT and paid caregivers regardless of payer source.
Caregiver/Agency
Information
Type of Care
(e.g. HHA,
HM, SN, PT,
ADC, MOW,
ERS, etc)
Amount &
Frequency
(e.g. 2 hrs
6 x wk)
Payer Source
(Medicare,
Private Pay,
etc)
Date
Care
Started
Is Caregiver
from a home
care
agency?
Name: ______________
Address:_____________
Phone: ______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
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21
CONDENSED REASSESSMENT TOOL
If there are unpaid caregivers providing services to the insured, please complete the following
section:
Are there any family or unpaid caregivers providing services?
Yes
No
If “Yes,” Name: __________________________________ Relationship __________________________
How long is unpaid care expected to be needed? ____________________________________________
How many hours a week of unpaid care is received? _________________________________________
What unpaid services are you receiving? ___________________________________________________
Who is your main caregiver or person who helps you the most?
Name: ______________________________________________________________________________
Address:_____________________________________________________________________________
Phone Number (s): Home _________________ Work ________________ Cell ____________________
Relationship:
Spouse
Child
Sibling
Parent
Friend
Other: __________________
TO BE COMPLETED BY THE ASSESSOR
The insured receives assistance a TOTAL of ___ hours per day ___ days per week, including care
provided by family.
Yes
No
Current level of care is appropriate
If No what would be appropriate level of care to meet the current needs of the insured?
____________________
LTC Claims Advisory Committee Guide 2007
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