A Report on the Actuarial, Marketing, and Legal Analyses of the CLASS Program. A. Measuring “Substantial Assistance”

10/14/2011

The CLASS Program benefit trigger requires that an individual must be unable to perform at least the minimum number (which may be 2 or 3) of activities of daily living as are required under the plan for the provision of benefits without substantial assistance (as defined by the Secretary) from another individual. As noted earlier, this contractor recommends that “substantial assistance” should be defined to include not only hands-on and standby assistance but also the assistance needed by a person with cognitive impairment who cannot perform the ADL independently, that is, assistance to initiate the ADL at the right time and in the right place and to complete the steps required to perform the ADL successfully.

Need for assistance to perform ADLs is usually determined with generic assessment instruments developed by Katz et al. (1963), Lawton and Brody (1969) and others. Some researchers and clinicians have developed assessment instruments intended specifically for people with cognitive impairment and dementia. Many of these instruments measure IADLs as well as ADLs, and many provide potentially useful wording to identify the kinds of difficulties people with cognitive impairment often experience in performing ADLs, and therefore the kinds of assistance they need to perform the ADLs successfully.

Assessment Instruments To Measure ADLs and IADLs in People with Cognitive Impairment and Dementia

  • AD Situational Test (Skurla et al. 1988)
  • Dependence Scale (Rating based on informant responses to 13 questions about functional activities) (Stern et al., 1994)
  • Direct Assessment of Functional Status (DAFS) (Observation and rating on tasks in 7 functional areas) (Lowenstein et al., 1989)
  • Dressing Performance Scale (Observation and rating on 34 steps in dressing) (Beck 1988)
  • Functional Activities Questionnaire (Informant report on 10 functional activities (Pfeffer et al. 1982)
  • Refined ADL Assessment Scale (Observation and rating on 14 tasks) (Tappen 1994)
  • Self-Care Performance Tool (Observation and rating on 4 self-care activities (Thralow and Rueter1993)

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