Applicant Screen

This instrument was developed for the National Long-Term Care Channeling Demonstration. This project was conducted by Mathematica Policy Research, Inc. under contract #HHS-100-80-0157 and Temple University under contract #HHS-100-80-0133 for the Department of Health and Human Services (HHS) Office of Social Services Policy (now Office of Disability, Aging and Long-Term Care Policy), as well as additional funding from the HHS Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and HHS Administration on Aging. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.

NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form.

OMB APPROVAL NO: 0990-0074
EXPIRES: 9/30/84

NATIONAL LONG TERM CARE DEMONSTRATION
APPLICANT SCREEN

This report is authorized by law (Older Americans Act, Section 421: Social Security Act, Sections 1110, 1115, 1875 and 1881: and Public Health Service Act, Sections 1536 and 1533d). While you are not required to respond, your cooperation is needed to make the results of the survey comprehensive, accurate and timely.

SCREENER ID: [_____]_____] - [_____]_____]_____]_____]
APPLICANT ID: [_____]_____] - [_____]_____]_____]_____]_____] - [_____]

STATUS:

S1. FINAL STATUS:

COMPLETE . . . . . 01
INCOMPLETE . . . . . 02 COMPLETE A13

S2. CURRENT SCREEN:

APPROPRIATE . . . . . 01
INAPPROPRIATE . . . . . 02 COMPLETE A13

ASSIGNMENT:

S3. NEW ASSIGNMENT . . . . . 01
PREVIOUS ASSIGNMENT. . . . . 02

S4. CLIENT . . . . . 01
CONTROL . . . . . 02 COMPLETE A13

S5. SUBSAMPLE STATUS

YES NO
a. CAREGIVER 01 02
b. PROVIDER 01 02

COMPLETE . . . . . 01
INCOMPLETE . . . . . 02 COMPLETE A13

Mathematica Policy Research
December 1981

This questionnaire was prepared for the Department of Health and Human Services under Contract No. HHS-100-80-0157

SECTION A

THERE ARE NO RESTRICTIONS ON RESPONDENTS FOR SECTION A.

INTEREST, ELIGIBILITY AND REFERRAL

A1. APPLICANT'S ARE:

[_____]_____]_____]

A2. APPLICANT'S DATE OF BIRTH:

MONTH [_____]_____] DAY [_____]_____] YEAR [_____]_____]_____]_____]
NO INFORMATION . . . . . -1

A3. RESIDENCE WITHIN CATCHMENT AREA:

YES . . . . . 01
NO . . . . . 02

A4. IS A CURRENTLY INSTITUITONALIZE?

NO . . . . . 01 (A9)
YES, ACUTE HOSPITAL . . . . . 02
YES, CHRONIC HOSPITAL . . . . . 03
YES, NURSING HOME . . . . . 04

[_____] SKILLED
[_____] INTERMEDIATE

A5. IS A CURRENTLY CERTIFIED AS LIKELY TO BE DISCHARGED TO A NONINSTITUTIONAL SETTING WITHIN 3 MONTHS?

YES . . . . . 01 A6
NO . . . . . 02 (A7)

A6. EXPECTED DISCHARGE DATE:

MONTH [_____]_____] DAY [_____]_____] YEAR [_____]_____]
Certified by: _________________________
Position: _________________________

A7. IF IN ACUTE HOSPITAL, IS A CERTIFIED FOR DISCHARGE AND HOSPITALIZED PENDING APPROPRIATE PLACEMENT?

YES . . . . . 01 A8
NO . . . . . 02 (A9)
NO INFORMATION . . . . . -1 (A9)

A8. FOR HOW LONG HAS A BEEN CERTIFIED FOR DISCHARGE, BUT HOSPITALIZED PENDING PLACEMENT?

DAYS . . . . . [_____]_____]_____]
NO INFORMATION . . . . . -1

A9. HAS THE PROGRAM BEEN DESCRIBED TO A AND IS A INTERESTED IN PARTICIPATING IN THE SCREENING PROCESS?

YES . . . . . 01
NO . . . . . 02

CONTINUE SCREENING PROCESS ONLY IF APPLICANT:

IS AT LEAST 65 YEARS OLD

AND

RESIDES IN CATCHMENT AREA

AND

IS NOT INSTITUTIONALIZED OR IS CERTIFIED FOR DISCHARGE

AND

IS INTERESTED IN PARTICIPATING IN THE SCREENING PROCESS

IF THESE FOUR CONDITIONS HOLD, CONTINUE WITH IDENTIFICATION SHEET

COMPLETE ID1-ID8 BEFORE PROCEEDING WITH A10 BELOW.

A10. DATE OF REFERRAL:

MONTH [_____]_____] DAY [_____]_____] YEAR [_____]_____]

REFERRAL SOURCE

CHANNELING OUTREACH . . . . . 01	HOME DELIVERED MEALS . . . . . 09	CASEWORK/CASE MANAGEMENT AGENCY . . . . . 17
ACUTE/REHAB HOSPITAL DISCHARGE . . . . . 02	SR CENTER/NUTRITION . . . . . 10	ADULT DAY CARE . . . . . 18
NURSING HOME DISCHARGE . . . . . 03	PSYCHIATRIC FACILITY . . . . . 11	FAMILY MEMBER . . . . . 19
NURSING HOME SCREEN . . . . . 04	COUNSELING SERVICE . . . . . 12	FRIEND OR NEIGHBOR . . . . . 20
NURSING HOME WAITING LIST . . . . . 05	INFORMATION AND REFERRAL . . . . . 13	SELF . . . . . 21
PHYSICIAN . . . . . 06	LEGAL/ADVOCACY . . . . . 14	OTHER (SPECIFY) . . . . . 22
HOME HEALTH AGENCY . . . . . 07	PUBLIC WELFARE DEPARTMENT . . . . . 15
HOME-MAKING SERVICE . . . . . 08	MEDICAID DEPARTMENT . . . . . 16

A12. PRESENTING PROBLEMS/REASONS FOR REFERRAL.

A. DESCRIPTION (AS DESCRIBED BY REFERRAL SOURCE AND APPLICANT, NOTE SOURCE OF DESCRIPTION)

PROBLEM/REFERRAL CODE: (CIRCLE ALL THAT APPLY)

CHANGE IN FUNCTIONAL CAPACITY DUE TO ILLNESS/INJURY . . . . . 01
EMOTIONAL OR BEHAVIOR PROBLEMS . . . . . 02
DISORIENTATION . . . . . 03
EXISTING SERVICES INADEQUATE/UNSATISFACTORY (APART FROM CHANGE IN APPLICANT FUNCTIONING) . . . . . 04
PERMANENT LOSS OF CAREGIVER . . . . . 05
CAREGIVER EXHAUSTION . . . . . 06
TEMPORARY ABSENCE OR INABILITY OF CAREGIVER . . . . . 07

EXPECTED DURATION OF ABSENCE . . . . . [_____]_____]

WEEKS . . . . . 01
MONTHS . . . . . 02
NO INFORMATION . . . . . -1

OTHER (SPECIFY) . . . . . 08

A13. IF INCOMPLETE, INAPPROPRIATE OR CONTROL GROUP MEMBER, DESTINATION TO WHICH A WAS REFERRED:

NAME:_________________________
[_____]_____] USE CODES FROM A11 ABOVE

SCREENING WORKSHEET ON FUNCTIONAL IMPAIRMENT

A. ACTIVITIES OF DAILY LIVING (ADL)

	LEVEL OF IMPAIRMENT
	SLIGHT OR NONE (I)	MODERATE (M)	SEVERE (S)	NO INFORMATION
Eating	01	02	03	-1
Bed and/or chair transfer	01	02	03	-1
Dressing	01	02	03	-1
Bathing	01	02	03	-1
Toileting	01	02	03	-1
Continence	01	02	03	-1

B. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

	NOT SEVERELY IMPAIRED	SEVERELY IMPAIRED (S)	NO INFORMATION
Meal preparation	01	02	-1
Housekeeping/ shopping*	01	02	-1
Medications	01	02	-1
Telephone/travel/ money management*	01	02	-1
Functional impairment associated with cognitive or behavioral problems*	01	02	-1
* Severe impairment in one or more areas within this category is to be counted as severely impaired.

SECTION B

THIS SECTION IS NOT TO BE ASKED OF A SELF-RESPONDENT. SECTION C BEGINS ON PAGE 5.

B1. Does A display:

	YES	NO	NO INFORMATION
a. disorientation, confusion, impairment of judgment, or memory loss?	01	02	-1
b. inappropriate behaviors?	01	02	-1

B2. IF EITHER B1a OR B1b ANSWERED "YES":

Is A's ability to perform daily activities affected nearly every day or is daily supervision required to ensure personal safety?

YES, ACTIVITIES AFFECTED OR SUPERVISION REQUIRED . . . . . 01 S
NO . . . . . 02
NO INFORMATION . . . . . -1

IF ACTIVITIES AFFECTED OR SUPERVISION REQUIRED, COUNT AS ONE SEVERE IADL IMPAIRMENT.

B3. Does A have a legal guardian?

YES . . . . . 01 RECORD NAME, ADDRESS, AND TELEPHONE IN ID10.
NO . . . . . 02
NO INFORMATION . . . . . -1

B4. In your judgment, will A's family and friends be able to continue to give (him/her) the amount of help they do now?

YES . . . . . 01
NOT SURE . . . . . 02
NO . . . . . 03 (B6) F
NO HELP AT PRESENT . . . . . 04
NO INFORMATION . . . . . -1

SUPPORT SYSTEM IS FRAGILE IF NOT ABLE TO MAINTAIN CURRENT HELP.

B5. In your judgment, will A's family and friends be able to give (him/her) (more) help if it is needed?

YES . . . . . 01
NOT SURE . . . . . 02
NO . . . . . 03
NO INFORMATION . . . . . -1

SUPPORT SYSTEM IS FRAGILE IF NOT ABLE TO HELP MORE OR NO CURRENT HELP AND NOT ABLE TO HELP.

B6. Would A need someone to assist or translate in an in-person interview?

YES . . . . . 01 RECORD NAME, ADDRESS, AND TELEPHONE IN ID9. HELP REQUIRED/LANGUAGE: _________________________
NO . . . . . 02
NO INFORMATION . . . . . -1

B7. Is A able to communicate in English over the telephone?

YES . . . . . 01
NO . . . . . 02 COMMUNICATION PROBLEM/LANGUAGE: _________________________
NO INFORMATION . . . . . -1

SECTION C

THERE ARE NO RESTRICTIONS ON RESPONDENTS FOR SECTION C

C1. LIVING ARRANGEMENT: IF INSTITUTIONALIZED, PRIOR LIVING ARRANGEMENT. (CIRCLE ALL THAT APPLY)

ALONE . . . . . 01 (C3)
WITH SPOUSE . . . . . 02
WITH A'S CHILD(REN) . . . . . 03
WITH OTHER RELATIVES . . . . . 04
WITH NON-RELATIVES . . . . . 05
NO INFORMATION . . . . . -1 (C3)

C2. OTHER HOUSEHOLD MEMBERS 65 OR OLDER? IF INSTITUTIONALIZED, PRIOR HOUSEHOLD MEMBERS.

YES . . . . . 01 RECORD FULL NAMES IN ID11.
NO . . . . . 02
NO INFORMATION . . . . . -1

C3. RESIDENCE IN PERSONA CARE HOME? PROBE: Do you live in a special place where you can get help taking care of yourself, like LOCAL TERMS FOR HOMES PROVIDING PERSONAL CARE? IF INSTITUTIONALIZED, PRIOR RESIDENCE.

YES . . . . . 01
NO . . . . . 02
NO INFORMATION . . . . . -1

C4. IS BIRTHDATE COMPLETED IN A2?

YES . . . . . 01
NO . . . . . 02 AS AND RECORD IN A2.

C5. APPLICANT'S SEX:

MALE . . . . . 01
FEMALE . . . . . 02

C6. RACIAL OR ETHNIC BACKGROUND: PROBE: Are you of Spanish origin?

AMERICAN INDIAN AND ALASKAN NATIVE . . . . . 01
ASIAN OR PACIFIC ISLANDER . . . . . 02
BLACK, NOT OF HISPANIC ORIGIN . . . . . 03
HISPANIC . . . . . 04
WHITE, NOT OF HISPANIC ORIGIN . . . . . 05
NO INFORMATION . . . . . -1

C7. APPLICANT'S HEALTH INSURANCE COVERAGE: PROBE: Is something deducted from your Social Security check for Medicare? PROBE: Do you have a SITE COLOR (Medicaid) card?

	YES	NO	NO INFORMATION
a. MEDICARE, PLAN A FOR HOSPITAL BILLS	01	02	-1
b. MEDICARE, PLAN B FOR DOCTOR BILLS	01	02	-1
c. MEDICAID	01	02	-1
d. PRIVATE INSURANCE	01	02	-1

IF MEDICARE AND/OR MEDICAID, COMPLETE NUMBERS IN ID6-ID7, AS NECESSARY.

C8. IS A CURRENTLY INSTITUTIONALIZED?

YES . . . . . 01 (SECTION D)
NO . . . . . 02

C9. DOES A REGULARLY HAVE HELP NOW WITH--

	YES	NO	NO INFORMATION
a. MEAL PREPARATION	01	02	-1
b. HOUSEWORK OR SHOPPING?	01	02	-1
c. TAKING MEDICINE?	01	02	-1
d. MEDICAL TREATMENTS AT HOME?	01	02	-1
e. PERSONAL CARE (EATING, GETTING OUT OF BED OR A CHAIR, DRESSING, BATHING AND USING THE TOILET)?	01	02	-1

C10. NAMES OF ORGANIZATIONS OR AGENCIES PROVIDING HELP REGULARLY:

SECTION D

D. PHYSICAL ACTIVITIES OF DAILY LIVING

QUESTIONS IN SECTION D ARE TO BE ASKED ONLY OF SELF-RESPONDENTS, SIGNIFICANT OTHERS, REGULAR CAREGIVERS, OR SOMEONE WHO HAS RECENTLY ASSESSED THE APPLICANT IN A FACE-TO-FACE SITUATION. SECTION E BEGINS ON PAGE 14.

INSTRUCTIONS:

ASK ABOUT APPLICANT'S USUAL ABILITY TO PERFORM ACTIVITIES DURING THE PAST WEEK. (USUAL = HALF THE TIME OR MORE) INCLUDE SUPERVISION IN THE SAME ROOM (OR NEARBY ROOM FOR TOILETING), AS HUMAN ASSISTANCE.

The next few questions are about the things you do by yourself and the help other people give. Please tell me if someone stays in the room in case you need help with any of the things we talk about.

Please answer these questions in terms of your activities during the past week.

EATING

D1a. First, I'd like to talk about eating. Does someone help you eat? DO NOT INCLUDE HELP WITH CUTTING MEAT OR BUTTERING BREAD.

YES, SOMEONE HELPS . . . . . [_____]
NO, BY SELF . . . . . [_____] (D1) I
DID NOT EAT AT ALL IN PAST WEEK (IV, TUBES) . . . . . [_____] (D1) S₁
NO INFORMATION . . . . . [_____] (D1)

D1b. Does someone feed you? PROBE: For most of the meal?

YES . . . . . [_____] S₂
NO . . . . . [_____] M
NO INFORMATION . . . . . [_____]

D1. EATING, EXCLUDING CUTTING MEAT AND BUTTING BREAK

DID NOT EAT AT ALL IN PAST WEEK (IV, TUBES) . . . . . 01 S₁
IS FED BY OTHERS . . . . . 02 S₂
OTHER HUMAN ASSISTANCE . . . . . 03 M
NO HUMAN ASSISTANCE . . . . . 04 I
NO INFORMATION . . . . . -1

BED/CHAIR TRANSFER

D2a. Does someon help you get out of bed or a chair? IF HELP WITH BED AND/OR CHAIR, CODE "YES."

YES, SOMEONE HELPS . . . . . [_____]
NO, BY SELF . . . . . [_____] (D2) I
BEDBOUND (DID NOT GET OUT OF BED AT ALL IN PAST WEEK) . . . . . [_____] (D2) S₁
NO INFORMATION . . . . . [_____] (D2)

D2b. Does someone lift you?

YES . . . . . [_____] S₂
NO . . . . . [_____] M
NO INFORMATION . . . . . [_____]

D2. BED/CHAIR TRANSFER

BEDBOUND (DID NOT GET OUT OF BED AT ALL IN PAST WEEK) . . . . . 01 S₁
IS LIFTED FOR BED AND/OR CHAIR TRANSFER . . . . . 02 S₂
OTHER HUMAN ASSISTANCE IN BED AND/OR CHAIR TRANSFER . . . . . 03 M
NO HUMAN ASSISTANCE FOR EITHER . . . . . 04 I
NO INFORMATION . . . . . -1

DRESSING

D3a. The next questions are about dressing--that is, getting clothes and putting them on.

Does someone help you to get dressed or to change your night clothes? DO NOT INCLUDE HELP WITH TYPING SHOES OR GROOMING.

YES, SOMEONE HELPS . . . . . [_____]
NO, BY SELF . . . . . [_____] (D3) I
DID NOT CHANGE CLOTHES AT ALL IN PAST WEEK . . . . . [_____] S₁
NO INFORMATION . . . . . [_____] (D3)

D3b. Does someone (dress you/change your night clothes for you)?

YES . . . . . [_____] S₂
NO . . . . . [_____] M
NO INFORMATION . . . . . [_____]

D3. DRESSING, INCLUDING GETTING CLOTHES

DID NOT CHANGE CLOTHES AT ALL IN PAST WEEK . . . . . 01 S₁
DRESSED BY OTHERS/OTHERS CHANGE NIGHT CLOTHES . . . . . 02 S₂
OTHER HUMAN ASSISTANCE IN DRESSING/CHANGING NIGHT CLOTHES . . . . . 03 M
NO HUMAN ASSISTANCE . . . . . 04 I
NO INFORMATION . . . . . -1

BATHING

D4a. The next questions are about bathing--including turning on the water.

Does someone help you bathe? COUNT HELP WITH TUB/SHOWER TRANSFER AS HELP. IF MULTIPLE METHODS USED, PROBE: Which do you usually use for a full bath?

YES, SOMEONE HELPS . . . . . [_____]
NO, BY SELF . . . . . [_____] (D4) I₁
BEDBATHS (DID NOT BATHE AT ALL IN PAST WEEK) . . . . . [_____] (D4) S₁
NO INFORMATION . . . . . [_____] (D4)

D4b. IS A CURRENTLY INSTITUTIONALIZED?

YES . . . . . 01
NO . . . . . 02 (D4d)

D4c. IF INSTITUTIONALIZED: Does someone help you or just stay near you in case you need help?

SOMEONE HELPED WITH WASHING OR TRANSFER . . . . . [_____]
SOMEONE JUST STAYED NEAR . . . . . [_____] (D4) I₂
NO INFORMATION . . . . . [_____]

D4d. Does someone help you wash more than your back or feet? HELP WITH BACK AND FEET ONLY CONSIDERED MODERATE IMPAIRMENT. EXCLUDE HELP WITH SHAMPOOING.

YES . . . . . [_____] S₂
NO . . . . . [_____] M
NO INFORMATION . . . . . [_____]

D4. BATHING, AT A SINK OR BASIN OR IN A TUB OR SHOWER, INCLUDING TURNING ON WATER AND TUB/SHOWER TRANSFER.

BEDBATHS (DID NOT BATHE AT ALL IN PAST WEEK) . . . . . 01 S₁
HUMAN HELP WITHING MORE THAN BACK AND/OR FEET (EXCLUDE SHAMPOOING). . . . . 02 S₂
OTHER HUMAN ASSISTANCE . . . . . 03 M
NO HUMAN ASSISTANCE . . . . . 04 I₁
IF INSTITUTIONALIZED, SUPERVISION ONLY . . . . . 05 I₂
NO INFORMATION . . . . . -1

TOILETING

D5a. The next questions are about personal care. The first one is about using the toilet.

Does someone help you get to the bathroom to use the toilet? PROBE: Or don't you use a toilet for either your bowel or bladder functions?

YES, SOMEONE HELPS . . . . . [_____] M
NO, BY SELF . . . . . [_____] I
DID NOT USE TOILET AT ALL IN PAST WEEK (BEDPAN, BEDSIDE COMMODE, CATHETER, COLOSTOMY) . . . . . [_____] S₁
NO INFORMATION . . . . . [_____]

D5. TOILETING, INCLUDING GETTING TO BATHROOM

DID NOT USE TOILET AT ALL IN PAST WEEK (BEDPAN, BEDSIDE COMMODE, CATHETER, COLOSTOMY) . . . . . 01 S
HUMAN ASSISTANCE IN USING TOILET. . . . . 02 M
NO HUMAN ASSISTANCE . . . . . 03 I
NO INFORMATION . . . . . -1

CONTINENCE

D6a. Do you use a device such as a catheter bag or colostomy bag?

YES . . . . . [_____]
NO . . . . . [_____] (D6c)
NO INFORMATION . . . . . [_____] (D6c)

D6b. Do you change (this/your DEVICE by yourself?

YES, SELF CARE . . . . . [_____]
NO, HELP WITH CARE . . . . . [_____] (D6) S₂
NO INFORMATION . . . . . [_____]

D6c. During the past week, did you accidently wet or soil yourself, either day or night? PROBE: At least once?

YES . . . . . [_____] S₂
NO . . . . . [_____] I
NO INFORMATION . . . . . [_____]

D6. CONTINENCE

INCONTINENT AT LEAST ONCE DURING PAST WEEK . . . . . 01 S₁
HUMAN ASSISTANCE WITH CHANGING DEVICE (E.G., CATHETER BAG OR COLOSTOMY BAG). . . . . 02 S₂
SELF CARE OF DEVICE (E.G., CATHETER BAG OR COLOSTOMY BAG AND NOT INCONTINENT DURING PAST WEEK. . . . . 03 M
NOT INCONTINENT AT ALL DURING PAST WEEK . . . . . 04 I
NO INFORMATION . . . . . -1

D7. TYPE OF RESPONDENT FOR SECTION D:

SELF . . . . . 01
SIGNIFICANT OTHER/REGULAR CAREGIVER . . . . . 02
RECENT ASSESSOR . . . . . 03

D8. DOES APPLICANT HAVE AT LEAST 2 MODERAGE ADL IMPAIRMENTS?

YES . . . . . 01 (F1)
NO . . . . . 02

D9. IS APPLICANT BEDBOUND (DOES NOT GET OUT OF BED OR ONLY IF LIFTED)? (SEE D2.)

YES . . . . . 01
NO . . . . . 02 (SECTION E)
NO INFORMATION IN D2 . . . . . 03 (SECTION E)

D10. For how long have you been unable to get out of bed -- has it been more than one month?

YES, MORE THAN ONE MONTH . . . . . 01 (ES)
NO, ONE MONTH OR LESS . . . . . 02
NO INFORMATION . . . . . -1

SECTION E

E. INSTRUMENTAL ACTIVITIES OF DAILY LIVING

QUESTIONS IN SECTION E SHOULD BE ASKED ONLY OF SELF-RESPONDENTS, SIGIFICANT OTHERS, REGULAR CAREGIVERS, OR SOMEONE WHO HAS RECENTLY ASSESSED THE APPLICANT IN A FACE-TO-FACE SITUATION. SECTION F BEGINS ON PAGE 16.

INSTRUCTIONS:

The next questions are about activities that are usually done in a household, such as shopping, cooking, and cleaning. I know that not everyone does these things. I would like to find out whether you are able to do them.

ASK ABOUT APPLICANT'S CURRENT CAPACITY (USUAL CAPACITY DURING LAST WEEK). USUAL = HALF THE TIME OR MORE.

E1. Can you prepare a light meal, such as a sandwich, by yourself? PROBE: If the rules permitted/If someone else didn't do it/ If you had a kitchen.

YES . . . . . 01
NO . . . . . 02 S
NO INFORMATION . . . . . -1

E2. Can you do light work around the house, such as washing dishes, by yourself? PROBE: If someone else didn't do it/If the rules permitted/If you wanted to.

YES . . . . . 01
NO . . . . . 02 S
NO INFORMATION . . . . . -1

E3. Can you shop for groceries if someone goes with you to help you manage? PROBE: If you had transportation/If someone else didn't do it.

YES . . . . . 01
NO . . . . . 02 S
NO INFORMATION . . . . . -1

E4. Can you travel in a van, taxi, or car if someone goes with you to help you manage? IF DOES NOT TRAVEL AT ALL, PROBE: What about trips to the doctor?

YES . . . . . 01
NO . . . . . 02 S
DOES NOT TRAVEL AT ALL . . . . . 03 S
NO INFORMATION . . . . . -1

E5. The next question is about taking medicine. If someone measures out the amount of medicine beforehand and reminds you to take it, can you do the rest by yourself?

YES . . . . . 01
NO . . . . . 02 S
NO INFORMATION . . . . . -1

E6. Can you take care of money for day-to-day purchases by yourself?

YES . . . . . 01
NO . . . . . 02 S
NO INFORMATION . . . . . -1

E7. Can you answer the telephone and call the operator by yourself? IF CAN DO WITH AN AMPLIFIED OR OTHER SPECIALLY EQUIPPED TELEPHONE, CODE AS ABLE TO DO.

CAN DO ONE . . . . . 01
BOTH . . . . . 02
NEITHER . . . . . 03 S
NO INFORMATION . . . . . -1

E8. TYPE OF RESPONDENT FOR SECTION E:

SELF . . . . . 01
SIGNIFICANT OTHER/REGULAR CAREGIVER . . . . . 02
RECENT ASSESSOR . . . . . 03

E9. DOES APPLICANT HAVE 3 SEVERE IADL IMPAIRMENTS OR 2 SEVERE IADL IMPAIRMENTS AND 1 SEVERE ADL IMPAIRMENT?

YES . . . . . 01
NO . . . . . 02 (F2)

SECTION F

THE QUESTIONS IN SECTION F ARE TO BE ASKED ONLY OF SELF-RESPONDENTS OR SIGNIFICANT OTHERS.

F1. (When you leave the (hospital/nursing home)), do you feel that you (will) need more help with -- PROBE: Not counting help you have.

	YES	NO	NO INFORMATION
a. meal preparation?	01	02	-1
b. housework or shopping?	01	02	-1
c. taking your medicine?	01	02	-1
d. medical treatments at home?	01	02	-1
e. personal care, that is, eating, getting in an out of bed, dressing, bathing, and using the toilet?	01	02	-1

F2. Finally, we need to know your income to help us understand what kind of people are interested in our program. It does not affect whether you can participate in the program or not.

Before taxes and deductions, about how much income did you (and your (husband/wife)) have last month from all sources? PROBE: Your best estimate will be fine.

MONTHLY INCOME . . . . . $[_____]_____]_____]_____] (END)
NO INCOME . . . . . 00 (END)
NO INFORMATION . . . . . -1

F3. Could you give me an idea of the range? Was it --

less than $500, . . . . . 01
between $500 and $1,000, . . . . . 02
or $1,000 or more a month? . . . . . 03
NO INFORMATION . . . . . -1

F4. IS A CURRENTLY INSTITUTIONALIZED?

YES . . . . . 01 ASCERTAIN INTEREST
NO . . . . . 02 S

F5. Are you now on a waiting list to go to a nursing home or have you applied in the last two months?

ON WAITING LIST OR HAS APPLIED . . . . . 01
NEITHER . . . . . 02
NO INFORMATION . . . . . -1

ASCERTAIN INTEREST FROM APPLICANT. IF APPLICANT CANNOT COMMUNICATE, ASCERTAIN INTEREST FROM LEGAL GUARDIAN OR WITNESS
THANK RESPONDENT

END INTERVIEW

COMPLETE ID12 - ID 15

LEVEL OF ADL IMPAIRMENT

	SEVERE	MODERATE
EATING	DID NOT EAT (IV, TUBES) IS FED	OTHER HUMAN ASSISTANCE
BED/CHAIR TRANSFER	BEDBOUND LIFTED IN BED AND/OR CHAIR TRANSFER	OTHER HUMAN ASSISTANCE IN BED AND/OR CHAIR TRANSFER
DRESSING	DID NOT CHANGE CLOTHES IS DRESSED	OTHER HUMAN ASSISTANCE (EXCLUDING SHOE TYING AND GROOMING)
BATHING	BEDBATHS/DID NOT BATHE HELP IN WASHING MORE THAN BACK OR FEET (EXCLUDING SHAMPOOING)	OTHER HUMAN ASSISTANCE (EXCEPT SUPERVISION, IF INSTITUTIONALIZED)
TOILETING	DID NOT USE TOILET	ANY HUMAN ASSISTANCE
CONTINENCE	INCONTINENT AT LEAST, ONCE IN PAST WEEK HUMAN ASSISTANCE WITH EQUIPMENT	EQUIPMENT USE WITH SELF CARE

NATIONAL LONG-TERM CARE CHANNELING DEMONSTRATION REPORTS AVAILABLE

A Guide to Memorandum of Understanding Negotiation and Development

HTML http://aspe.hhs.gov/daltcp/reports/mouguide.htm

PDF http://aspe.hhs.gov/daltcp/reports/mouguide.pdf

An Analysis of Site-Specific Results

Executive Summary http://aspe.hhs.gov/daltcp/reports/sitees.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/sitees.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/sitees.pdf

Analysis of Channeling Project Costs

Executive Summary http://aspe.hhs.gov/daltcp/reports/projctes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/projctes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/projctes.pdf

Analysis of the Benefits and Costs of Channeling

Executive Summary http://aspe.hhs.gov/daltcp/reports/1986/costes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/cost.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/cost.pdf

Applicant Screen Set

HTML http://aspe.hhs.gov/daltcp/reports/1982/appscset.htm

PDF http://aspe.hhs.gov/daltcp/reports/1982/appscset.pdf

Assessment and Care Planning for the Frail Elderly: A Problem Specific Approach

HTML http://aspe.hhs.gov/daltcp/reports/1986/asmtcare.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/asmtcare.pdf

Assessment Training for Case Managers: A Trainer's Guide

HTML http://aspe.hhs.gov/daltcp/reports/1985/asmttran.htm

PDF http://aspe.hhs.gov/daltcp/reports/1985/asmttran.pdf

Case Management Forms Set

HTML http://aspe.hhs.gov/daltcp/reports/1985/cmforms.htm

PDF http://aspe.hhs.gov/daltcp/reports/1985/cmforms.pdf

Case Management Training for Case Managers: A Trainer's Guide

HTML http://aspe.hhs.gov/daltcp/reports/1985/cmtrain.htm

PDF http://aspe.hhs.gov/daltcp/reports/1985/cmtrain.pdf

Channeling Effects for an Early Sample at 6-Month Follow-up

Executive Summary http://aspe.hhs.gov/daltcp/reports/6monthes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1985/6monthes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1985/6monthes.pdf

Channeling Effects on Formal Community-Based Services and Housing

Executive Summary http://aspe.hhs.gov/daltcp/reports/commtyes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/commty.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/commty.pdf

Channeling Effects on Hospital, Nursing Home and Other Medical Services

Executive Summary http://aspe.hhs.gov/daltcp/reports/hospites.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/hospites.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/hospites.pdf

Channeling Effects on Informal Care

Executive Summary http://aspe.hhs.gov/daltcp/reports/informes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/informes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/informes.pdf

Channeling Effects on the Quality of Clients' Lives

Executive Summary http://aspe.hhs.gov/daltcp/reports/qualtyes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/qualtyes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/qualtyes.pdf

Clinical Baseline Assessment Instrument Set

HTML http://aspe.hhs.gov/daltcp/reports/cbainstr.htm

PDF http://aspe.hhs.gov/daltcp/reports/cbainstr.pdf

Community Services and Long-Term Care: Issues of Negligence and Liability

HTML http://aspe.hhs.gov/daltcp/reports/negliab.htm

PDF http://aspe.hhs.gov/daltcp/reports/negliab.pdf

Differential Impacts Among Subgroups of Channeling Enrollees

Executive Summary http://aspe.hhs.gov/daltcp/reports/enrolles.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/enrolles.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/enrolles.pdf

Differential Impacts Among Subgroups of Channeling Enrollees Six Months After Randomization

Executive Summary http://aspe.hhs.gov/daltcp/reports/difimpes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1984/difimpes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1984/difimpes.pdf

Examination of the Equivalence of Treatment and Control Groups and the Comparability of Baseline Data

Executive Summary http://aspe.hhs.gov/daltcp/reports/baslines.htm

HTML http://aspe.hhs.gov/daltcp/reports/1984/baslines.htm

PDF http://aspe.hhs.gov/daltcp/reports/1984/baslines.pdf

Final Report on the Effects of Sample Attrition on Estimates of Channeling's Impacts

Executive Summary http://aspe.hhs.gov/daltcp/reports/1986/atritnes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/atritn.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/atritn.pdf

Informal Care to the Impaired Elderly: Report of the National Long-Term Care Demonstration Survey of Informal Caregivers

Executive Summary http://aspe.hhs.gov/daltcp/reports/impaires.htm

HTML http://aspe.hhs.gov/daltcp/reports/1984/impaires.htm

PDF http://aspe.hhs.gov/daltcp/reports/1984/impaires.pdf

Informal Services and Supports

HTML http://aspe.hhs.gov/daltcp/reports/1985/infserv.htm

PDF http://aspe.hhs.gov/daltcp/reports/1985/infserv.pdf

Initial Research Design of the National Long-Term Care Demonstration

HTML http://aspe.hhs.gov/daltcp/reports/designes.htm

PDF http://aspe.hhs.gov/daltcp/reports/designes.pdf

Issues in Developing the Client Assessment Instrument for the National Long-Term Care Channeling Demonstration

HTML http://aspe.hhs.gov/daltcp/reports/1981/instrues.htm

PDF http://aspe.hhs.gov/daltcp/reports/1981/instrues.pdf

Methodological Issues in the Evaluation of the National Long-Term Care Demonstration

Executive Summary http://aspe.hhs.gov/daltcp/reports/methodes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/methodes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/methodes.pdf

National Long-Term Care Channeling Demonstration: Summary of Demonstration and Reports

HTML http://aspe.hhs.gov/daltcp/reports/1991/chansum.htm

PDF http://aspe.hhs.gov/daltcp/reports/1991/chansum.pdf

Screening Training for Screeners: A Trainer's Guide

HTML http://aspe.hhs.gov/daltcp/reports/1985/scretrai.htm

PDF http://aspe.hhs.gov/daltcp/reports/1985/scretrai.pdf

Survey Data Collection Design and Procedures

Executive Summary http://aspe.hhs.gov/daltcp/reports/sydataes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/sydataes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/sydataes.pdf

Tables Comparing Channeling to Other Community Care Demonstrations

HTML http://aspe.hhs.gov/daltcp/reports/1986/tablees.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/tablees.pdf

The Channeling Case Management Manual

HTML http://aspe.hhs.gov/daltcp/reports/1986/cmmanual.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/cmmanual.pdf

The Channeling Financial Control System

HTML http://aspe.hhs.gov/daltcp/reports/1985/chanfcs.htm

PDF http://aspe.hhs.gov/daltcp/reports/1985/chanfcs.pdf

The Comparability of Treatment and Control Groups at Randomization

HTML http://aspe.hhs.gov/daltcp/reports/compares.htm

PDF http://aspe.hhs.gov/daltcp/reports/compares.pdf

The Effects of Case Management and Community Services on the Impaired Elderly

Executive Summary http://aspe.hhs.gov/daltcp/reports/casmanes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/casmanes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/casmanes.pdf

The Effects of Sample Attrition on Estimates of Channeling's Impacts for an Early Sample

HTML http://aspe.hhs.gov/daltcp/reports/1984/earlyes.htm

PDF http://aspe.hhs.gov/daltcp/reports/1984/earlyes.pdf

The Evaluation of the National Long-Term Care Demonstration: Final Report

Executive Summary http://aspe.hhs.gov/daltcp/reports/chanes.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/chanfr.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/chanfr.pdf

The Evaluation of the National Long-Term Care Demonstration

Executive Summary http://aspe.hhs.gov/daltcp/reports/hsres.htm

HTML http://aspe.hhs.gov/daltcp/reports/1988/hsre.htm

PDF http://aspe.hhs.gov/daltcp/reports/1988/hsre.pdf

The Planning and Implementation of Channeling: Early Experiences of the National Long-Term Care Demonstration

Executive Summary http://aspe.hhs.gov/daltcp/reports/implees.htm

HTML http://aspe.hhs.gov/daltcp/reports/1983/imple.htm

PDF http://aspe.hhs.gov/daltcp/reports/1983/imple.pdf

The Planning and Operational Experience of the Channeling Projects

Executive Summary http://aspe.hhs.gov/daltcp/reports/proceses.htm

HTML http://aspe.hhs.gov/daltcp/reports/1986/proceses.htm

PDF http://aspe.hhs.gov/daltcp/reports/1986/proceses.pdf

INSTRUMENTS AVAILABLE

Applicant Screen

HTML http://aspe.hhs.gov/daltcp/instruments/1981/AppSc.htm

PDF http://aspe.hhs.gov/daltcp/instruments/1981/AppSc.pdf

Client Contact Log

HTML http://aspe.hhs.gov/daltcp/instruments/ClConLog.htm

PDF http://aspe.hhs.gov/daltcp/instruments/ClConLog.pdf

Client Tracking/Status Change Form

HTML http://aspe.hhs.gov/daltcp/instruments/ClTracFm.htm

PDF http://aspe.hhs.gov/daltcp/instruments/ClTracFm.pdf

Clinical Assessment and Research Baseline Instrument: Community Version

HTML http://aspe.hhs.gov/daltcp/instruments/carbicv.htm

PDF http://aspe.hhs.gov/daltcp/instruments/carbicv.pdf

Clinical Baseline Assessment Instrument: Community Version

HTML http://aspe.hhs.gov/daltcp/instruments/cbaicv.htm

PDF http://aspe.hhs.gov/daltcp/instruments/cbaicv.pdf

Clinical Baseline Assessment Instrument: Institutional Version

HTML http://aspe.hhs.gov/daltcp/instruments/cbaiiv.htm

PDF http://aspe.hhs.gov/daltcp/instruments/cbaiiv.pdf

Eighteen Month Followup Instrument

HTML http://aspe.hhs.gov/daltcp/instruments/18mfi.htm

PDF http://aspe.hhs.gov/daltcp/instruments/18mfi.pdf

Followup Instrument

HTML http://aspe.hhs.gov/daltcp/instruments/FolInst.htm

PDF http://aspe.hhs.gov/daltcp/instruments/FolInst.pdf

Informal Caregiver Followup Instrument

HTML http://aspe.hhs.gov/daltcp/instruments/ICFolIns.htm

PDF http://aspe.hhs.gov/daltcp/instruments/ICFolIns.pdf

Informal Caregiver Survey Baseline

HTML http://aspe.hhs.gov/daltcp/instruments/ICSurvey.htm

PDF http://aspe.hhs.gov/daltcp/instruments/ICSurvey.pdf

Screening Identification Sheet

HTML http://aspe.hhs.gov/daltcp/instruments/ScrIDSh.htm

PDF http://aspe.hhs.gov/daltcp/instruments/ScrIDSh.pdf

Time Sheet

HTML http://aspe.hhs.gov/daltcp/instruments/TimeSh.htm

PDF http://aspe.hhs.gov/daltcp/instruments/TimeSh.pdf

Twelve Month Followup Instrument

HTML http://aspe.hhs.gov/daltcp/instruments/12mfi.htm

PDF http://aspe.hhs.gov/daltcp/instruments/12mfi.pdf

To obtain a printed copy of this report, send the full report title and your mailing information to:

U.S. Department of Health and Human Services
Office of Disability, Aging and Long-Term Care Policy
Room 424E, H.H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
FAX: 202-401-7733
Email: webmaster.DALTCP@hhs.gov

Files

AppSc_0.pdf (pdf, 1.64 MB)

Applicant Screen

NATIONAL LONG TERM CARE DEMONSTRATION APPLICANT SCREEN

SECTION A

SECTION B

SECTION C

SECTION D

SECTION E

SECTION F

NATIONAL LONG-TERM CARE CHANNELING DEMONSTRATION REPORTS AVAILABLE

INSTRUMENTS AVAILABLE

Connect with Us

NATIONAL LONG TERM CARE DEMONSTRATION
APPLICANT SCREEN