Clinical Baseline Assessment Instrument: Institutional Version

07/08/1983


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

Assessment Date(s):  _________________________
Assessment Interview:  _________________________

Client Name:  _________________________
I.D. Number:  [_____]_____]  -  [_____]_____]_____]_____]_____]  -  [_____]
Birth Date:  _________________________
Sex:  M     F
Respondent:  Client     Proxy

NATIONAL LONG TERM CARE DEMONSTRATION

CLINICAL BASELINE ASSESSMENT INSTRUMENT
INSTITUTIONAL VERSION

 

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.

CLINICAL NOTES FROM THE SCREEN
 
CONTACTS IN THE INSTITUTION
 

Mathematica Policy Research and Temple University
July 8, 1983

This questionnaire was prepared for the Department of Health and Human Services under Contract No. HHS-100-80-0157 and Contract No. HHS 100-80-0133.

COMPLETE INFORMED CONSENT FORMS

First, I'd like to find out a little about you and your living situation.

You may have recently answered a few questions similar to the ones I am going to ask now. It is important that I ask them again so that we will have the same information on everyone.

A1. Are you married, widowed, divorced or separated, or have you never been married?

MARRIED . . . . . 01
WIDOWED . . . . . 02
DIVORCED . . . . . 03
SEPARATED . . . . . 04
NEVER MARRIED . . . . . 05
NOT ANSWERED . . . . . -1

[HOW LONG] _____

A2. Before you entered the (hospital/nursing home), did you live alone?

YES, ALONE . . . . . 01 (A6)
NO, WITH OTHERS . . . . . 02
NO, IN GROUP HOME, NOT WITH RELATIVES . . . . . 03 (A6)
NOT ANSWERED . . . . . -1

[TYPE OF RESIDENCE] _________________________

A3. Please tell me the names of everyone who usually lived with you, before you entered the (hospital/nursing home).

COUNT HOUSEHOLD MEMBERS OF USUAL HOME PRIOR TO INSTITUTIONALIZATION.

A4. How old is NAME?

A5. How is NAME related to you?

NOT ANSWERED . . . . . -1

  NAME     AGE     RELATIONSHIP  
     
     
     
     
     
     
     

A6. Are you considering going back to your home when you leave the (hospital/nursing home)? PROBE: Do you still own or rent that home?

YES . . . . . 01
NO, NO LONGER AVAILABLE . . . . . 02
NO, OTHER REASON . . . . . 03
NOT SURE . . . . . 04
NOT ANSWERED . . . . . -1

[COMMENTS] _________________________

A7. Do you have any children (besides those you mentioned as living with you)? INCLUDE ONLY LIVING CHILDREN.

YES How many? . . . . . [_____]_____]
NO . . . . . 00 (A9)
NOT ANSWERED . . . . . -1 (A9)

  [NAME]     [ADDRESS]     [TELEPHONE]  
     
     
     
     
     
     
     

A8. (Do any of these children/Does this child) live within one-half hour travel time of your home? PROBE: Of your home before you entered the (hospital/nursing home)?

YES How many? . . . . . [_____]_____]
NO . . . . . 00
NOT ANSWERED . . . . . -1

A9. Could you please tell me the name, address, and phone number of someone we might contact in case we have trouble getting in touch with you?

  NAME     ADDRESS     TELEPHONE  
     
     
     
     
     
     
     

A10. What is the highest grade or year you finished in school? IF UNGRADED OR FOREIGN SCHOOL, PROBE: About what grade would that be equal to (in this country)?

NO SCHOOLING . . . . . 00
ELEMENTARY (01-08) . . . . . [_____]_____]
HIGH SCHOOL (09-12) . . . . . [_____]_____]
COLLEGE/GRADUATE (13-18+) . . . . . [_____]_____]
NOT ANSWERED . . . . . -1

A11. READ CATEGORIES IF NECESSARY:

What is your racial or ethnic background? PROBE: Are you of Spanish origin?

AMERICAN INDIAN OR ALASKAN NATIVE . . . . . 01
ASIAN OR PACIFIC ISLANDER . . . . . 02
BLACK, NOT OF HISPANIC ORIGIN . . . . . 03
HISPANIC . . . . . 04
WHITE, NOT OF HISPANIC ORIGIN . . . . . 05
NOT ANSWERED . . . . . -1

 

B. PHYSICAL HEALTH

The next questions are about your physical health.

B1. How would you rate your overall health at the present time--would you say

excellent, . . . . . 01
good, . . . . . 02
fair, . . . . . 03
or poor? . . . . . 04
NOT ANSWERED . . . . . -1

B2. Before you entered the (hospital/nursing home), did you have a regular source of medical care, like a family doctor or a clinic?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

  [NAME]     [ADDRESS]     [TELEPHONE]  
     
     
     
     
     
     
     

B3. In the last year, how many times were you admitted to any kind of hospital (counting this time)? IF IN NURSING HOME, PROBE: Before you entered the nursing home?

ADMISSIONS . . . . . [_____]_____]
NONE . . . . . 00
NOT ANSWERED . . . . . -1

TRANSFER BETWEEN HOSPITALS=MULTIPLE ADMISSIONS.

  [HOSPITAL]     [DATE]     [REASON]  
     
     
     
     
     
     
     

B4. In the last year, were you a resident in a nursing home, convalescent home or similar place? IF YES, PROBE: Any other nursing home admissions?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

  [NURSING HOME]     [DATE]     [REASON]  
     
     
     
     
     
     
     

B5. IF NOT IN A NURSING HOME, ASK: Have you applied to get into a nursing home?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[WHERE] _________________________
[ATTITUDE TOWARD NURSING HOME] _________________________

B6. Now I am going to read you a list of health conditions and illnesses. Please tell me if you have any of them at the present time.

IF YES B7. Are you currently being treated for this condition?
    YES     NO     NA     YES     NO     NA  
a. First, do you have anemia (tired blood, iron-poor blood)? 01 02 -1 01 02 -1
b. High blood pressure? 01 02 -1 01 02 -1
c. Angina or heart trouble, e.g., heart attacks? 01 02 -1 01 02 -1
d. Effects of a stroke? 01 02 -1 01 02 -1
e. Diabetes? 01 02 -1 01 02 -1
f. Arthritis or pain in your joints? 01 02 -1 01 02 -1
g. Cancer, leukemia, or a tumor? 01 02 -1 01 02 -1
h. Nerve or muscle problems like neuralgia, Parkinson's disease or seizures? 01 02 -1 01 02 -1
i. Respiratory problems like asthma, emphysema, or bronchitis? 01 02 -1 01 02 -1
j. Skin problems like a rash, eczema, or bed sores? 01 02 -1 01 02 -1
k. Broken or dislocated bones? 01 02 -1 01 02 -1
l. Paralysis? 01 02 -1 01 02 -1
m. Do you have any (other) health conditions or illnesses we haven't talked about? (SPECIFY) 01 02 - 01 02 -1
PROBE: Anything else? 01 02 -1 01 02 -1

[DETAILS OF HEALTH CONDITIONS/RISK FACTORS. INCLUDE SMOKING, ALCOHOL CONSUMPTION, COMPLIANCE WITH DOCTOR'S ORDERS.] _________________________

B8a. I would like some information about the medicines you take regularly.

IF CLIENT: May I have your permission to ask your nurse about your prescriptions after we finish talking? (CHECK APPROPRIATE BOX.)

[_____] YES, PERMISSION GRANTED (WHEN SPEAKING TO NURSE, PROBE FOR EYEDROPS, SUPPOSITORIES, AND INJECTIONS.)
[_____] NO, PERMISSION REFUSED

IF PROXY OR PERMISSION REFUSED: What prescriptions do you take regularly now, in the (hospital/nursing home)? PROBE FOR EYEDROPS, SUPPOSITORIES, AND INJECTIONS.

B8b. Are there any non-prescription medicines you take regularly like vitamins, aspirin, or laxatives? REGULARLY = ON A ROUTINE BASIS AT THE PRESENT TIME.

  MEDICINE     DOSAGE     FREQUENCY     DOCTOR     DATE  
         
         
         
         
         
         
         

B9. The next question is about medical treatments you may have at home, after you leave the (hospital/nursing home).

At home, will you have medical treatments like injections, therapies, oxygen, or changing of bandages?

YES . . . . . 01
NO . . . . . 02 (B11)
UNCERTAIN . . . . . 03 (B11)
NOT ANSWERED . . . . . -1 (B11)

[TREATMENTS] _________________________
[WHO WILL DO IT] _________________________
[FREQUENCY] _________________________
[PRIOR HOME HEALTH AGENCY] _________________________

B10. Do you feel that you will need more help to carry out these treatments than you will have at home? IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NEEDED] _________________________

B11. Often what you eat is important to your health. Could you please tell me what you usually eat? READ CATEGORIES IF NECESSARY. CIRCLE ALL THAT APPLY.

DAIRY PRODUCTS, SUCH AS MILK, CHEESE OR YOGURT . . . . . 01
"PROTEIN FOODS", SUCH AS MEAT, POULTRY, FISH, EGGS, OR DRIED BEANS . . . . . 02
FRUITS OR VEGETABLES -- EITHER RAW, COOKED OR CANNED . . . . . 03
FOODS MADE FROM GRAINS, SUCH AS BREAD, CEREAL, NOODLES, OR RICE . . . . . 04
DOES NOT EAT AT ALL (IV TUBES) . . . . . 06
NOT ANSWERED . . . . . -1

[DETAILS] _________________________

B12. I have some questions about special diets.

IF CLIENT: May I have your permission to ask your nurse about that after we finish talking?

IF PERMISSION GRANTED, ASK B12. OF NURSE.

IF PROXY OR PERMISSION REFUSED: Are you on a special diet?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[TYPE] _________________________
[WHO PRESCRIBED] _________________________

B13. Now, I'd like to talk about special equipment you may use. Do you use any of the following special equipment or aids now?

    YES     NO     NOT ANSWERED  
a. Dentures? 01 02 -1
b. A cane? 01 02 -1
c. A walker? 01 02 -1
d. A wheelchair? 01 02 -1
e. A brace? 01 02 -1
f. A pacemaker (for your heart)? 01 02 -1
g. A hearing aid? 01 02 -1
h. Glasses or contact lenses? 01 02 -1
i. Any other special equipment that I haven't mentioned? (SPECIFY) 01 02 -1

[EQUIPMENT USE] _________________________

IF THE CLIENT HAS BEEN UNABLE TO GET OUT OF BED FOR MORE THAN ONE MONTH, OR WHEN LIFTED OUT STILL CANNOT AMBULATE, SKIP TO B16.

INDOOR MOBILITY

B14. The next questions are about getting around indoors, on the floor of the (hospital/nursing home).

How do you usually get around inside?

(SPECIFY) _________________________
[PROBLEMS WITH MOBILITY/AMBULATION] _________________________

B15. IF IN WHEELCHAIR, CODE WITHOUT ASKING.

How difficult is it for you to climb one flight of stairs -- is it: PROBE: If there were stairs here, how difficult would it be for you to climb them?

not difficult, . . . . . 01
somewhat difficult, . . . . . 02
very difficult, or . . . . . 03
can't you do it at all? . . . . . 04
IN WHEELCHAIR . . . . . 05
NOT ANSWERED . . . . . -1

B16. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with getting around inside (than you will have at home)? IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

OUTDOOR MOBILITY

B17. What about outdoors? How do you usually get around when you go outdoors? USUALLY = HALF THE TIME OR MORE DURING THE PAST MONTH

DOES NOT GO OUTDOORS . . . . . [_____]

(SPECIFY) _________________________

SENSORY IMPAIRMENT

B18. (With your glasses or lenses) can you see well enough to read the labels on your medicine bottles or see the numbers on a telephone? IF FOREIGN, PROBE: Could you read a CLIENT'S NATIVE LANGUAGE newspaper?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

_________________________

B19. CAN THE CLIENT HEAR WELL ENOUGH TO UNDERSTAND NORMAL CONVERSATION (WITH A HEARING AID IF USUALLY WORN)?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

_________________________

B20. WHICH OF THE FOLLOWING BEST DESCRIBES THE CLIENT'S SPEECH?

PARTIALLY IMPAIRED (CAN USUALLY BE UNDERSTOOD BUY HAS DIFFICULTY WITH SOME WORDS) . . . . . 01
SEVERELY IMPAIRED (CAN BE UNDERSTOOD ONLY WITH DIFFICULTY AND CANNOT CARRY ON A NORMAL CONVERSATION) . . . . . 02
COMPLETELY IMPAIRED (SPEECH IS UNINTELLIGIBLE OR CANNOT SPEAK) . . . . . 03

 

C. PHYSICAL ACTIVITIES OF DAILY LIVING

EATING

C1. The next questions are about taking care of yourself.

First, I'd like to ask you abut help with eating.

During the past week, did someone usually help you eat or stay in the room in case you needed help eating? DO NOT CODE HELP WITH CUTTING MEAT OR BUTTERING BREAD. USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK.

YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (C3)
IV, TUBES . . . . . 03 (C4)
NOT ANSWERED . . . . . -1 (C3)

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

C2. Did someone usually feed you?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

C3. When you leave the (hospital/nursing home) do you feel that you will need (help/more help) with eating (than you will have at home)? IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

BED AND CHAIR TRANSFER

C4. During the past week, did someone usually help you get out of bed or a chair or stay in the room in case you needed help? IF HELP WITH BED AND/OR CHAIR, CODE "YES".

YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (C6)
DID NOT GET OUT OF BED AT ALL . . . . . 03 (C7)
NOT ANSWERED . . . . . -1 (C6)

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

C5. Did someone usually lift you out of bed or a chair?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[SPECIAL EQUIPMENT USED] _________________________

C6. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with getting out of bed or a chair (than you will have at home)?

IF NO, PROBE: What about special equipment, will you need that?

IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

DRESSING

C7. The next questions are about dressing -- that is, getting clothes and putting them on (including your brace).

During the past week, did you usually get dressed for the day or did you stay in night clothes?

GOT DRESSED . . . . . 01
STAYED IN NIGHT CLOTHES . . . . . 02
DID NOT CHANGE CLOTHES AT ALL . . . . . 03 (C10)
NOT ANSWERED . . . . . -1 (C10)

C8. Did someone help you (dress/change your night clothes) or stay in the room in case you needed help? DO NOT CODE HELP IN TYING SHOES OR GROOMING.

YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (C10)
NOT ANSWERED . . . . . -1 (C10)

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

C9. Did someone usually (dress you/change your night clothes for you)?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

C10. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with dressing (than you will have at home)? IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

BATHING

C11. The next questions are about bathing -- including turning on the water.

During the past week when you had a full bath, did you usually bathe in a tub or shower, at a sink or basin, or did you have bedbaths? IF MULTIPLE METHODS USED, PROBE: Which did you usually use for a full bath?

IN TUB OR SHOWER . . . . . 01
IN SINK OR BASIN . . . . . 02
BEDBATHS . . . . . 03
DID NOT HAVE FULL BATH . . . . . 04
NOT ANSWERED . . . . . -1

[IF BEDBATH, WHO HELPS] _________________________

C12. Did someone usually help you get in or out of the tub or shower or stay in the room in case you needed help?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

C13. During the past week, did someone usually help you bathe (at the sink or basin) or stay in the room in case you needed help?

YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (C15)
NOT ANSWERED . . . . . -1 (C15)

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

C14. Did someone help you wash more than your back or feet? DO NOT CODE HELP WITH SHAMPOOING HAIR.

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

C15. Did you usually use special equipment to help you bathe, like (a tub stool or grab bar/handle bars at the sink)?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[TYPE] _________________________

C16. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with bathing (than you will have at home)?

IF NO, PROBE: What about special equipment, will you need that?

IF YES, PROBE: More help than is aranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

TOILETING

C17. The next questions are about personal care. The first one is about using the toilet.

During the past week, did you usually go to the bathroom to use the toilet?

PROBE: For either your bowel or bladder functions?

IF NO, PROBE: What did you usually use? _________________________

YES, TOILET FOR AT LEAST ONE FUNCTION . . . . . 01
NO (BEDPAN, BEDSIDE COMMODE) . . . . . 02 (C22)
NO (CATHETER, COLOSTOMY) . . . . . 03 (C20)
NOT ANSWERED . . . . . -1 (C20)

[IF BEDPAN/COMMODE, WHO HELPS] _________________________

C18. Did someone usually help you get to the bathroom to use the toilet or stay nearby in case you needed help?

YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02
NOT ANSWERED . . . . . -1

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

C19. During the past week, did you usually use special equipment like a grab bar or raised toilet seat to help you use the toilet?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[TYPE] _________________________

C20. Do you use a device such as a catheter bag or colostomy bag?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1 (C22)

[TYPE] _________________________

C21. Do you change (this/your DEVICE) by yourself?

SELF CARE . . . . . 01
HELP WITH CARE . . . . . 02
NOT ANSWERED . . . . . -1

[WHO HELPS] _________________________

C22. During the past week, did you accidentally wet or soil yourself, either day or night?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with (using the toilet/caring for your bladder and bowel functions)?

IF NO, PROBE: What about special equipment, will you need this?

IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

 

D. INSTRUMENTAL ACTIVITIES OF DAILY LIVING

IF CLIENT HAS BEEN UNABLE TO GET OUT OF BED FOR MORE THAN ONE MONTH, OR WHEN LIFTED OUT STILL CANNOT AMBULATE, ASK ONLY THE QUESTIONS MARKED WITH A STAR .

MEAL PREPARATION

D1. These next questions are about things done in a household, such as cleaning and cooking. In most (hospitals/nursing homes) there is no opportunity to do these things. I'd like to know whether you are able to do them.

Considering how you've been feeling the past week, could you prepare full meals, such as meat and a vegetable, by yourself? PROBE: If the rules permitted/If someone else didn't do it/If you had a kitchen.

YES, USUALLY BY SELF . . . . . 01 (D4)
NO, NOT USUALLY HAS HELPE/NO MEALS PREPARED . . . . . 02
NOT ANSWERED . . . . . -1 (D3)

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

D2. What is the reason you (get help preparing/don't prepare) meals?

(SPECIFY) _________________________

D3. Could you prepare light meals, such as a sandwich, by yourself?

CAN PREPARE LIGHT MEALS . . . . . 01
CANNOT . . . . . 02
NOT ANSWERED . . . . . -1

D4. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with meal preparation (than you will have at home)? IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

HOUSEKEEPING

D5. Considering how you have been feeling the past week, could you do heavy work around the house, such as cleaning floors, by yourself? PROBE: If someone else didn't do it/If the rules permitted.

YES, USUALLY BY SELF . . . . . 01 (D7)
NO, USUALLY HAS HELP . . . . . 02
NO WORK DONE AROUND THE HOUSE . . . . . 03
NOT ANSWERED . . . . . -1

  [WHO HELPS]     [HOW]     [REASON]  
     
     
     
     
     
     
     

D6. Could you do light work around the house, such as washing dishes, by yourself?

COULD DO LIGHT HOUSEWORK . . . . . 01
NOT AT ALL . . . . . 02
NOT ANSWERED . . . . . -1

D7. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with work around the house (than you will have at home)? PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

SHOPPING

D8. Considering how you've been feeling the past week, could you go grocery shopping by yourself? PROBE: If you had transportation/If someone else didn't do it.

YES, USUALLY BY SELF . . . . . 01 (D10)
NO, USUALLY HAS HELP . . . . . 02
NOT ANSWERED . . . . . -1

  [WHO HELPS]     [HOW]     [REASON]  
     
     
     
     
     
     
     

D9. Could you go grocery shoping if someone went with you to help you manage? PROBE: If you had transportation.

YES, COULD WITH HELP . . . . . 01
NO, COULD NOT GO AT ALL . . . . . 02
NOT ANSWERED . . . . . -1

D10. When you leave the (hospital/nursing home), do you feel you will need (help/more help) with grocery shopping (than you will have at home)? IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
UNCERTAIN . . . . . 03
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

TAKING MEDICINE

D11. The next questions are about taking medicine.

Considering how you've been feeling the past week, could you take the correct amounts at the proper time without any help from another person? PROBE: If the rules permitted if/If someone else didn't do it.

YES . . . . . 01 (D14)
NO . . . . . 02
NOT ANSWERED . . . . . -1 (D13)

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

D12. What is the reason you get help with taking medicine?

(SPECIFY) _________________________

D13. If someone measured out the amount of medicine beforehand and reminded you to take it, could you do the rest by yourself? IF NEEDS REMINDER AND/OR PREMEASURED AMOUNT, BUT CAN DO REST, CODE "YES".

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

D14. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with taking medicine (than you will have at home)? IF YES, PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

TRAVEL/TRANSPORTATION

D15. Before you entered the (hospital/nursing home), what kind of transportation did you usually use? PROBE: What about going to the doctor?

BUS/SUBWAY . . . . . 01
CAR/VAN/TAXI . . . . . 02
AMBULANCE ONLY . . . . . 03
DOES NOT TRAVEL AT ALL . . . . . 04 (D18)
NOT ANSWERED . . . . . -1 (D18)

D16. Before you entered the (hospital/nursing home), did you have help with transportation from an agency or organization like LOCAL NAME?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[AGENCY NAME] _________________________

D17. Could you travel in a car, van or taxi if someone goes with you to help you manage (considering how you've been feeling the past week)? CODE NO IF NEEDS HELP IN TRANSFER FROM DRIVER OF VAN OR TAXI.

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[ESCORT NEEDED] _________________________

  [WHO HELPS]     [HOW]  
   
   
   
   
   
   
   

D18. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with transportation (than you will have at home)? PROBE: More help than is arranged for you now?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

MONEY MANAGEMENT

D19. The next questions are about managing your money, regardless of how much or little you have.

Can you write checks or pay bills by yourself?

YES, USUALLY BY SELF . . . . . 01
NO, USUALLY HAS HELP . . . . . 02 (D22)
NO, HAS NO BILLS . . . . . 03
NOT ANSWERED . . . . . -1

[WHO HELPS] _________________________
[REASON HAS HELP/NO BILLS] _________________________

D20. Do you have a legal guardian, conservator, or payee?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[NAME] _________________________
[TYPE] _________________________
[ADDRESS] _________________________
[PHONE #] _________________________

D21. Can you take care of money for day-to-day purchases by yourself?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

D22. When you leave the (hospital/nursing home), do you feel that you will need (help/more help) with managing your money (than is arranged for you now)?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[HELP NOW ARRANGED] _________________________
[HELP STILL NEEDED] _________________________

TELEPHONE

The next questions are about using the telephone.

D23. Can you get telephone numbers and place the calls by yourself? PROBE: Can you do both?

ONE ONLY . . . . . 01
BOTH . . . . . 02 (D25)
NEITHER . . . . . 03
NOT ANSWERED . . . . . -1

[USES SPECIAL EQUIPMENT] _________________________
[NEEDS SPECIAL EQUIPMENT] _________________________

D24. Can you answer the telephone and call the operator by yourself? PROBE: Can you do both?

ANSWER ONLY . . . . . 01
CALL OPERATOR ONLY . . . . . 02
BOTH . . . . . 03
NEITHER . . . . . 04
NOT ANSWERED . . . . . -1

NOTE: IF CLIENT HAS BEEN INSITTUTIONALIZED FOR MORE THAN 2 MONTHS, ASK ONLY THE QUESTIONS MARKED WITH A STAR ON THE SUPPORT SYSTEM GRIDS.

D25. DID CLIENT LIVE ALONG BEFORE ENTERING THE (HOSPITAL OR NURSING HOME)? (See A2 and A3.) THOSE IN GROUP QUARTERS DO NOT LIVE ALONE.

YES . . . . . 01 (E7)
NO . . . . . 02
A2 or A3 NOT ANSWERED . . . . . 03

 

E. SERVICES AND SUPPORT

E1. Now I have some more questions about the people who helprd you before you entered the (hospital/nursing home). First, please tell me who lived with yu who regularly helped you to take care of yourself or who did things around the house.

ASK E2-E6 FOR EACH HOUSEHOLD CAREGIVER NAME 1 _________________________ NAME 2 _________________________ NAME 3 _________________________
NO HOUSEHOLD CAREGIVERS . . . . . -4 (E7)
E2. How is NAME related to you? _________________________
NOT ANSWERED . . . . . -1
_________________________
NOT ANSWERED . . . . . -1
_________________________
NOT ANSWERED . . . . . -1
E3. When is NAME generally at home to help you if you need it? CIRCLE ALL THAT APPLY WEEK NIGHTS . . . . . 01
WEEK DAYS . . . . . 02
WEEKENDS . . . . . 03
NOT ANSWERED . . . . . -1
WEEK NIGHTS . . . . . 01
WEEK DAYS . . . . . 02
WEEKENDS . . . . . 03
NOT ANSWERED . . . . . -1
WEEK NIGHTS . . . . . 01
WEEK DAYS . . . . . 02
WEEKENDS . . . . . 03
NOT ANSWERED . . . . . -1
E4. Is NAME employed? YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E5. What does NAME regularly help you with? PROBE: Anything else?

IF NO MENTION OF PERSONAL CARE, PROBE: Does NAME help you with eating, getting out of bed or a chair, dressing, bathing, or using the toilet?

PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
E6. WAS ANOTHER HOUSEHOLD CAREGIVER NAMED? YES (Repeat E2-E6) . . . . . 01
NO (GO TO E7) . . . . . 02
YES (Repeat E2-E6) . . . . . 01
NO (GO TO E7) . . . . . 02
GO TO E7

INFORMAL SUPPORT SYSTEM

E7. Next, please tell me the names of friends, neighbors or family members (who do not live with you) who regularly helped you before you entered the (hospital/nursing home). Please do not include people who helped you as part of their paid or volunteer work.

ASK E8-E13 FOR EACH INFORMAL CAREGIVER NAME 1 _________________________ NAME 2 _________________________ NAME 3 _________________________
NO HOUSEHOLD CAREGIVERS . . . . . -4 (E14)
E8. How is NAME related to you? _________________________
NOT ANSWERED . . . . . -1
_________________________
NOT ANSWERED . . . . . -1
_________________________
NOT ANSWERED . . . . . -1
E9. IF RELATIVE, is NAME employed? YES . . . . . 01
NO . . . . . 02
NOT RELATIVE . . . . . -4
NOT ANSWERED . . . . . -1
YES . . . . . 01
NO . . . . . 02
NOT RELATIVE . . . . . -4
NOT ANSWERED . . . . . -1
YES . . . . . 01
NO . . . . . 02
NOT RELATIVE . . . . . -4
NOT ANSWERED . . . . . -1
E10. About how long does NAME come to help you? PROBE: In the avg. week or month? [_____]_____] VISITS
PER WEEK . . . . . 01
PER MONTH . . . . . 02
NOT ANSWERED . . . . . -1
[_____]_____] VISITS
PER WEEK . . . . . 01
PER MONTH . . . . . 02
NOT ANSWERED . . . . . -1
[_____]_____] VISITS
PER WEEK . . . . . 01
PER MONTH . . . . . 02
NOT ANSWERED . . . . . -1
E11. About how long does NAME usually stay each visit? PROBE: On the avg? _____HOURS
_____MINS.
NOT ANSWERED . . . . . -1
_____HOURS
_____MINS.
NOT ANSWERED . . . . . -1
_____HOURS
_____MINS.
NOT ANSWERED . . . . . -1
E12. What does NAME regularly help you with? PROBE: Anything else?

IF NO MENTION OF PERSONAL CARE, PROBE: Does NAME help you with eating, getting out of bed or a chair, dressing, bathing, or using the toilet?

PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
E13. WAS ANOTHER INFORMAL CAREGIVER NAMED? YES (Repeat E8-E13) . . . . . 01
NO (GO TO E14) . . . . . 02
YES (Repeat E8-E13) . . . . . 01
NO (GO TO E14) . . . . . 02
GO TO E14

FORMAL SUPPORT SYSTEM

E14. Now, please tell me the people who regularly came to help you as part of their paid or volunteer work before you entered the (hospital/nursing home). These could be people who came from an agency or organization or people you or your family hired.

ASK E15-E19 FOR EACH FORMAL CAREGIVER NAME 1 _________________________ NAME 2 _________________________ NAME 3 _________________________
NO FORMAL CAREGIVERS . . . . . -4 (E20)
E15. Do you have a card or letter from the agency so that I can get the correct spelling? IF NO CARD, ASK FOR AGENCY NAME.

IF CANNOT NAME AGENCY, PROBE FOR HELPER'S NAME AND TELEPHONE NUMBER.

_________________________
_________________________
NOT WITH AGENCY . . . . . -1
NOT ANSWERED . . . . . -1
_________________________
_________________________
NOT WITH AGENCY . . . . . -1
NOT ANSWERED . . . . . -1
_________________________
_________________________
NOT WITH AGENCY . . . . . -1
NOT ANSWERED . . . . . -1
E16. How often does NAME come to help you? [_____]_____] VISITS
PER WEEK . . . . . 01
PER MONTH . . . . . 02
NOT ANSWERED . . . . . -1
[_____]_____] VISITS
PER WEEK . . . . . 01
PER MONTH . . . . . 02
NOT ANSWERED . . . . . -1
[_____]_____] VISITS
PER WEEK . . . . . 01
PER MONTH . . . . . 02
NOT ANSWERED . . . . . -1
E17. How long does NAME usually stay each visit? _____HOURS
_____MINS.
NOT ANSWERED . . . . . -1
_____HOURS
_____MINS.
NOT ANSWERED . . . . . -1
_____HOURS
_____MINS.
NOT ANSWERED . . . . . -1
E18. What does NAME regularly help you with? PROBE: Anything else?

IF NO MENTION OF PERSONAL CARE, PROBE: Does NAME help you with eating, getting out of bed or a chair, dressing, bathing, or using the toilet?

PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
PERSONAL CARE . . . . . 01
PREPARING MEALS . . . . . 02
HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03
TAKING MEDICINE . . . . . 04
MEDICAL TREATMENTS . . . . . 05
TRANSPORTATION . . . . . 06
MANAGING MONEY . . . . . 07
MONITORING . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09
NOT ANSWERED . . . . . -1
E19. WAS ANOTHER FORMAL CAREGIVER NAMED? YES (Repeat E15-E19) . . . . . 01
NO (GO TO E20) . . . . . 02
YES (Repeat E15-E19) . . . . . 01
NO (GO TO E20) . . . . . 02
GO TO E20

[INVOLVEMENT IN CASE MANAGEMENT PROGRAM PRIOR TO INSTITUTIONALIZATION.] _________________________

E20. The next questions are about things you may have done before you entered the (hospital/nursing home).

Did you regularly attend a social, religious, or recreational program like at a senior center or (church/temple)? REGULARLY = ON A RECURRING BASIS OF AT LEAST ONE VISIT A MONTH PRIOR TO INSTITUTIONALIZATION

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[WHERE] _________________________

E21. Did you regularly go to a group program where people helped you take care of yourself during the day like AREA PROGRAM TITLE? REGULARLY = ON A ROUTINE BASIS OF AT LEAST ONCE A WEEK PRIOR TO INSTITUTIONALIZATION

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[ANY MEALS THERE] _________________________
[DAILY ACTIVITIES] _________________________

 

F. MENTAL FUNCTIONING

*** THIS SECTION IS NOT TO BE ASKED OF A PROXY ***

F1. Now I'm going to read a list of questions to you. Please answer "Yes" or "No" for each of them.

    YES     NO     ASK  
a. Do you often have trouble getting to sleep or staying asleep? 01 02 -1
b. Do you often find yourself feeling unhappy or depressed? 01 02 -1
c. Are you troubled by your heart pounding or shortness of breath? 01 02 -1
d. Do you usually have a good appetite? 01 02 -1
e. Have you recently had periods of days or weeks when you couldn't "get going"? (you were constantly tired) 01 02 -1
f. Have you had crying spells or problems shaking off the blues? 01 02 -1
g. Do you often have trouble keeping your mind on what you are doing? 01 02 -1

F2. Do you find yourself feeling lonely quite often, sometimes, or almost never?

QUITE OFTEN . . . . . 01
SOMETIMES . . . . . 02
ALMOST NEVER . . . . . 03
NOT ANSWERED . . . . . -1

F3. Have you had any counseling or treatment for personal problems or emotional stress since DATE 6 MONTHS AGO?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[WHERE] _________________________

F4. (Besides your husband/wife), have any friends or family members you felt close to died within the past year?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

DO NOT ASK OF A PROXY RESPONDENT

F5. Sometimes when people get older, they have trouble remembering things. If you do not know the answers to some of the next questions, that's okay. It's very normal. It you do know the answers, the questions may seem obvious.

    CORRECT   INCORRECT/
  NOT ANSWERED  
a. What is the date today? _________________________ 01 02
b. What day of the week is it? _________________________ 01 02
c. What is the name of this place? PROBE: This hospital? This nursing home? _________________________
ROOM, NAME OF INSTITUTION ARE TYPICAL OF CORRECT RESPONSES.
01 02
d. What is your telephone number? IF CLIENT DOES NOT HAVE A PHONE, What is your street address? _________________________ 01 02
e. How old are you? _________________________ 01 02
f. When were you born? MO:__________ DAY: _____ YR: __________ CHECK COVER 01 02
g. What is the name of the President of the United States? _________________________ 02  
h. Who was President before this one? _________________________ 01 02
i. What was your mother's maiden name? _________________________ ACCEPT ANY SURNAME OTHER THAN CLIENT'S. 01 02
j. Subtract 3 from 20 and keep subtracting 3 from each new number you get, all the way down. PROBE: Can you subtract 3 from that? (17, 14, 11, 8, 5, 2) 01 02

Thank you. That's all of those questions.

  |_____|_____| NUMBER CORRECT  

F6. THINKING ABOUT THE CLIENT'S UNDERSTANDING OF THE QUESTIONS, MENTAL FUNCTIONING AND ABILITY TO COMMUNICATE, WOULD YOU SAY THE RESPONSES TO THE QUESTIONS ASKED OF HIM/HER WERE:

COMPLETELY RELIABLE . . . . . 01
RELIABLE ON MOST ITEMS . . . . . 02
RELIABLE ON SOME ITEMS . . . . . 03
COMPLETELY UNRELIABLE . . . . . 04
NO QUESTIONS ASKED OF SAMPLE MEMBER . . . . . -4

F7. DURING THE ASSESSMENT, DID THE CLIENT'S BEHAVIOR STRIKE YOU AS:

    YES     NO   CANNOT
  DETERMINE  
MENTALLY ALERT AND STIMULATING 01 02 03
PLEASANT AND COOPERATIVE 01 02 03
DEPRESSED AND/OR TEARFUL 01 02 03
FEARFUL, ANXIOUS, OR EXTREMELY TENSE 01 02 03
FULL OF UNREALISTIC COMPLAINTS 01 02 03
SUSPICIOUS (MORE THAN REASONABLE) 01 02 03
BIZARRE OR INAPPROPRIATE (E.G. DISRUPTIVE, WANDERING, ABUSIVE) 01 02 03
WITHDRAWN OR LETHARGIC 01 02 03
AGITATED, QUICK, LOUD, AND EMOTIONALLY OVERRESPONSIVE 01 02 03

[BEHAVIOR AND EMOTIONAL FUNCTIONING] _________________________

 

G. FINANCIAL RESOURCES

G1. The next questions are about your insurance.

Are you covered by --

    YES     NO   NOT
  ANSWERED  
a. Medicare? [# FROM CARD] _________________________ 01 02 -1
b. Medicaid? [# FROM CARD] _________________________ 01 02 -1

G2. Any (other) medical insurance or health plan such as Blue Cross, Blue Shield, VA or HMO?

[DETAILS/NUMBERS]   YES     NO   NOT
  ANSWERED  
  01 02 -1
  01 02 -1
  01 02 -1
  01 02 -1
  01 02 -1

G3. The next questions are about sources of income and assets you may have. This information is needed to see if you may be able to get services you do not now have.

Do you (and your husband/wife) now have any income from --

IF YES G4. What is the monthly amount of that income?
    YES      NO      NA     NOT
  ANSWERED  
a. Social Security or railroad retirement, including Social Security disability payments? PROBE: That is, a green check. EXCLUDE SSI. 01 02 -1 CLIENT:
SPOUSE:
BOTH:
-1
-1
-1
b. Other checks from the government such as SSI (that is, a gold check)? 01 02 -1 CLIENT:
SPOUSE:
BOTH:
-1
-1
-1
c. Veterans' disability payments? 01 02 -1 CLIENT:
SPOUSE:
BOTH:
-1
-1
-1
d. Retirement pensions? 01 02 -1   -1
e. Any other incomes? 01 02 -1   -1

G5. Before taxes and deductions, how much is your (and your husband's/wife's) total monthly income? ESTIMATE OK

$|_____|_____|_____|_____|
NOT ANSWERED . . . . . -1

G6. Before you entered the (hospital/nursing home), were you (or was anyone in your household) receiving food stamps?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[AMOUNT] _________________________

G7. Do you (and your husband/wife) have any assets like real estate (other than your usual home), savings accounts, saving certificates, stocks or bonds, or money market funds? PROBE: Do you have any bank accounts? IF OWNED BY SPOUSE, CODE "YES".

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[COMMENTS ON FINANCIAL ELIGIBILITY: FOLLOW SITE-SPECIFIC PROCEDURE.] _________________________

 

H. PHYSICAL ENVIRONMENT

H1. Do you (and your (husband/wife)) own or rent your (usual) home? IF HOME OWNED BY SPOUSE, CODE "OWNS OR IS BUYING". IF GROUP HOME, CODE AS "RENTS".

OWNS OR IS BUYING . . . . . 01
RENTS . . . . . 02
OCCUPIES RENT-FREE OR FOR EXCHANGE OF SERVICES . . . . . 03
OTHER (SPECIFY) _________________________ . . . . . 04
NOT ANSWERED . . . . . -1

[HOUSING EXPENSES] _________________________

H2. Do you receive any (other) assistance from the government in paying your rent?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[TYPE] _________________________

H3. In the past year, have you received any help from the federal, state or local government in paying your (fuel/electric) bills? PROBE: Under (the Energy Assistance Program/LOCAL NAME)?

YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1

[TYPE] _________________________

ASK OF CLIENT ONLY

 

IF IN THE HOSPITAL OR NURSING HOME FOR MORE THAN TWO MONTHS AND NOT RETURNING TO USUAL HOME (See A6), SKIP THIS SECTION AND TERMINATE THE INTERVIEW.

The last questions are about how you feel about your home. The purpose of these questions is to help us understand how people feel about where they live.

H4. Is there any thing about the structure of your home that makes it hard for you to go outside? PROBE FOR PROBLEMS RELATED TO ARCHITECTURE OR REPAIR.

CIRCLE ALL THAT APPLY
YES, STAIRS . . . . . 01
YES, OTHER PROBLEM . . . . . 02
NO . . . . . 03
NOT ANSWERED . . . . . -1

[PROBLEMS] _________________________

H5. How satisfied are you with the state of repairs or maintenance of your home? (Are you --

very satisfied, . . . . . 01
fairly satisfied, . . . . . 02
or not very satisfied?) . . . . . 03
NOT ANSWERED . . . . . -1

[COMMENTS] _________________________

H6. How safe do you feel inside your home at night? (Would you say very safe, somewhat safe, or very unsafe?)

VERY SAFE . . . . . 01
SOMEWHAT SAFE . . . . . 02
VERY UNSAFE . . . . . 03
NOT ANSWERED . . . . . -1

[COMMENTS] _________________________

H7. How satisfied are you with your home as a place to live? (Are you --

very satisfied, . . . . . 01
fairly satisfied, . . . . . 02
or not very satisfied?) . . . . . 03
NOT ANSWERED . . . . . -1

[COMMENTS] _________________________
[SATISFACTION WITH THINGS IN GENERAL] _________________________

H8. THE PHYSICAL ENVIRONMENT

[SPECIFY ENVIRONMENT] _________________________

CHECK IF A PROBLEM OBSERVED FOR EACH OF THE FOLLOWING:  
A. LOOSE, SHAKY STAIRS     M. PEELING PAINT    
B. BROKEN WINDOWS     N. NO CURTAINS OR SHADES    
C. ADEQUATE HANDRAILS ON STAIRS     O. INADEQUATE VENTILATION    
D. INTERIOR OR EXTERIOR IN NEED OF MAJOR REPAIRS     P. BLOCKED PATHWAYS/ACCESS TO FIRE EXITS    
E. NO DEADBOLT OR OTHER SECURE LOCK ON DOOR     Q. SLIPPERY, STICKY OR CLUTTERED FLOORS THAT MIGHT CAUSE SLIPPING OR TRIPPING    
F. FREEZING IN WINTER, SWELTERING IN SUMMER     R. EVIDENCE OF SPOILED FOOD    
G. FIRE HAZARDS SUCH AS UNSAFE HEATING OR LIGHTING EQUIPMENT OR BARE WIRES     S. DIRTY FOOD PREPARATION SURFACES    
H ACCUMULATION OF TRASH OR GARBAGE IN OR AROUND DWELLING UNIT     T. MORE THAN ONE DAY'S DIRTY DISHES IN SINK    
I. RATS OR MICE OR THEIR DROPPINGS     U. BEDDING NOT FRESH    
J. PRESENCE OR STRONG ODOR OF EXCREMENT     V. TOILET AREA FILTHY OR ODOROUS    
K. FLOODING OR STANDING WATER INSIDE     W. NO GRAB BARS NEAR TOILET AND/OR TUB    
L. INFESTATION WITH BUDS OR INSECTS        

/M-20
7/13/83


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/1983/cbaiiv.htm

PDF   http://aspe.hhs.gov/daltcp/instruments/1983/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/1982/ScrIDSh.htm

PDF   http://aspe.hhs.gov/daltcp/instruments/1982/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

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