Unpaid individuals who provide care and/or assistance to the person

Transcription

1 Caregiver About this Domain (Caregiver) Assessment Domains To assess the capacity of an informal caregiver to provide care and support to the individual and to identify resources to assist in the caregiving role Caregivers Unpaid individuals who provide care and/or assistance to the person Name Lives with Person Relationship Caregiver Role Type of Care Guardian/Legal Representative Partner/Significant (Displays if is Guardian/Legal Representative Partner/Significant (Displays if is (Displays if is (Displays if is Last update: 6/12/2017 Page 1 of 9

2 Guardian/Legal Representative Partner/Significant (Displays if is (Displays if is Guardian/Legal Representative Partner/Significant (Displays if is (Displays if is Guardian/Legal Representative Partner/Significant (Displays if is (Displays if is Note: There are 6 separate rows in the application to enter unpaid individuals. Notes/ Last update: 6/12/2017 Page 2 of 9

3 Caregiver Interview Name: Assessment Domains Relationship: Guardian/Legal Representative Partner/Significant Relative Non-Relative (Displays when Relative checked) (Displays when Non-Relative checked) Do you currently live in the same household as the individual you provide care for? Explain: (Displays when Yes is checked) How many miles between households? (Displays if No is checked above) Last update: 6/12/2017 Page 3 of 9

4 What kind of help do you give this individual? Arranging/Coordinating care, including clinic visits, etc. Housekeeping (such as meal preparation, cleaning & laundry) Managing medications (like helping set up) Money management Monitoring health (like blood pressure or diabetes) Paperwork like filing insurance claims or handling legal matters Personal Care (such as bathing, dressing, toileting, etc.) Shopping and errands for safety Transportation (Displays when is checked) (Displays when is checked) Assessment Domains In an average week, how many hours do you provide care for this individual? 2 hours or less (weekly) 3 10 hours hours hours Over 40 hours Don t know Do you or family have concerns about the individual s memory, thinking or ability to make decisions? Are you very concerned or somewhat concerned? (Displays if Yes is checked above) Very concerned Somewhat concerned Last update: 6/12/2017 Page 4 of 9

5 Are there any safety concerns that you have about this individual or their home environment? Explain: (Displays when Yes is checked) Given the individual s CURRENT CONDITION, have you ever considered placing him/her in a different type of care setting, such as a nursing home or another care facility for long-term placement? Probably not Definitely not Probably would Definitely would Does not apply individual is in care facility (Displays when Probably would or Definitely would is checked above) What issues might cause you to seriously consider a higher level of care for him/her or a transition into assisted living or a nursing home? How would you describe your own health? Excellent Good Fair Poor (Displays when Fair or Poor is checked above) Do your own health problems ever get in the way of providing care? Last update: 6/12/2017 Page 5 of 9

6 How would you rate your level of stress related to caring for this individual? ne Low Medium High Unsure Do you have difficulty getting a good night s sleep, 3 or more times a week? Sometimes Are you currently employed? Working full-time Working part-time t currently working Do you have anyone to help you with caregiving? Can you depend on this person to help you when you need it? (Displays when Yes is checked above) Explain: Unsure (Displays when No is checked) Last update: 6/12/2017 Page 6 of 9

7 Are you currently receiving any caregiver supports (e.g. respite, training or education, caregiver coaching or counseling or support groups? (Displays when Yes is checked above) Describe the supports/services and frequency: Are there any issues/obstacles that make it more difficult to provide support to the individual? Check all that apply: (Displays when Yes is checked above) High physical strain Memory care or behavior issues Financial pressures (limited income, unpaid bills) Decline in own physical health Decline in own emotional health (stress, anxiety, depression) needs Difficulty getting a good night s sleep Provide 20 or more hours of care per week Relationship issues/conflicts with individual or family Lack of support network (persons to help with caregiving) Care demands are too high Need (more) breaks from caregiving Have other caregiving responsibilities Balancing work and caregiving Employment is negatively impacted (Displays when is checked) Last update: 6/12/2017 Page 7 of 9

8 What activities do you enjoy doing? Are there activities that you enjoy that you would like to do more frequently? Is there anything needed to support or help you do these activities? Is there anything that would make it easier for you to provide care for this individual? Check all that apply: (Displays when Yes is checked above) Information Education or training (direct care skills, disease process) Help managing his/her memory care or behavior issues Help managing his/her care needs (medications, treatments) Help with finances Finding time for myself (respite, breaks from caregiving) One-to-one coaching or counseling Developing an informal network of support Dealing with family relationships and communications Home/safety modifications Technology and assistive devices Hiring my own help Help addressing my own care needs Balancing work, family and caregiving responsibilities Help with chemical or mental health issues for myself (Displays when is checked) Are you willing to be contacted by a community organization that can give you more information or assistance with caregiving? Notes/ Last update: 6/12/2017 Page 8 of 9

9 Referrals & Goals (Caregiver) Assessment Domains What is important to the individual? Referrals Needed: Caregiver Consultation Caregiver Training and Education Equipment and Supplies Financial and Legal Information Services Health/Disease Education Services Home and Vehicle Modification Services Hospice and End of Life Care Insurance Assistance/Information Mental Health Screening/Evaluation Primary Health Care Provider Respite Resources Transportation Services (Displays when this option is checked) (Displays when this option is checked) Assessed Needs and Support Plan Implications Last update: 6/12/2017 Page 9 of 9