Caregiver Relief Care Management Assessment Form

How to fill out Geriatric Caregiver Relief Assessment form:

(This form was originally put together to be filled out by a care manager such as a gerontologist care manager; however, you may be filling out this form yourself for a loved one. A detailed description on how to complete the caregiver relief form is below)

Part 1:

a. Medical History: This form can be printed out and used whenever is needed and an original copy can be saved and used for any future changes needed. When beginning to fill out the assessment form, fill in the Client’s name (person who is ill), address, phone number, and social security number. You do not need to fill out the referral.  The care manager would be the individual filling out the form for their loved one. When filling out the asses start date use the date in which you are filling out the form (e.g., today’s date). Persons attending assessment and persons contributing through consultation, you would use this to keep a record of who you interviewed to keep a record for your loved one. When filling out medical history enter the primary doctors name (e.g., Dr. Hunter) and the secondary doctors name which would be a neurologist, for example. Also include the doctor’s phone number. Next step is to fill out the diagnosis which can be obtained from your doctor, nurse, or someone in the office and often there is a secondary diagnosis or complications to the diagnosis. Someone may have Alzheimer’s with a secondary diagnosis of depression.  When filling out the medications your loved one is taking be sure to include the amount they are taking (e.g., 250 mg), the frequency in which they are taking the medication (e.g. 1 x day), the route (e.g., mouth), the rx# (e.g. rew12345), and who prescribed the medication.  Then be sure to write down what allergies they have and what the reaction (e.g. break out in hives, diff. breathing) to coming in contact with the allergy would be. What pharmacy did they use the phone number and the hours of the pharmacy?

b. Client Functioning: Physical (ADLs-activity of daily living, reported complaints), Mental (orientation, memory capacity). Orientated to time and place but not day and date. Previous functional abilities/any recent changes would include something like patient was cheerful and cooperative with guidance. Next are present functional (physical) abilities such as: poor balance, using walls, chairs, etc. to move around. Next you will fill out present functional abilities pertaining to the cognitive/psychological abilities. A checklist of cognitive/psychological abilities includes: dressing, eating, ambulating, gets in/out of bed, etc. Next to each activity of daily living mark whether the client is able to do the activity themselves or with supervision. If client needs supervision who is providing the client with assistance and how much assistance is needed. (e.g., daughter offers minimal assistance).  Instrumental activities of daily living include shopping, housework, etc. Mark if client is doing these activities themselves or with supervision and how much supervision is needed and how you assist client with each activity.

Part 2:

c. Nutrition: Mark each box accordingly that pertains to client. It is often the case someone over seventy years old is not functioning at their highest capacity and not eating as well as they should which is why they need a baseline. It is important for a caregiver to understand a client’s nutritional and daily eating habits. Someone may be on a soft food diet and the doctor needs to know that. This gives the caregiver a baseline and sense of the clients daily eating habits (e.g., I have teeth and mouth problems that make it difficult for me to eat; I eat fewer than two meals per day, I don’t always have enough money to buy the food I need, I eat alone most of the time, I am not always physically able to cook for myself, I take three or more different prescribed over the counter drugs a day which can change a person’s eating habits due to effects of the medication). The client’s nutritional score could be 0-2 Good or 3-5 Moderate nutritional risk. Add up all the boxes marked off to get the client’s nutritional score; so if there are eight boxes checked off the clients nutritional score would be 8. Next fill in the client’s weight. Fill in the observed weight if it is different than the client stated that you have observed. It is important to give accurate nutritional information such as client is a diabetic, low salt, allergies, dislikes tomatoes, etc. Fill in daily routine as it applies to food. Now you will come to the alcoholism (CAGE) section of the assessment form, which you want to find out if client has tried to cut down on their drinking, ever felt guilty about their drinking, etc. Fill in check boxes accordingly as it pertains to client; such as how many alcoholic beverages are they consuming daily. Next there will be a series of questions asking if the client has ever thought about suicide or have been feeling depressed.

d. Home Environment:

It is important to fill out client’s home environment; such as, does the client own, rent, etc. The environmental assessment pertains to home environment. Fill out check a box for client per which pertains to them. Some of these questions will include: does the patient use assistive devices correctly, are there sturdy handrails on the stairs and mark yes or no. Fill out all questions asked all questions are very important.

Part 3:

e. Crime/injury prevention and Communication

For each question mark yes or no accordingly that pertains to the client. For example, are there locks on the doors and windows, yes or no? Is the telephone handy, Yes or No? Answer all questions pertaining to communication and mark yes or no accordingly. For example, is the telephone easy to reach for the client, yes or no? Answer all questions pertaining to family/friends/pets. Each question will have a check mark to mark yes or no. Answer each question pertaining to the client you are filling out the form for. For example, are the neighbors supportive? Answer yes or no. Next, you will fill out the description of their living situation (e.g. who does the shopping?).

f. Support System:

This section of the caregiver relief form asks who the support system in the client’s life is. Fill in that person’s name, address, phone number, and their ability/willingness to help the client. This could be a family member, neighbor, old family friend, etc.

g. Spiritual/ Social Factors:

Next, fill out the client’s spiritual/social factors. This section will ask for the client’s church affiliation, religion, how they feel about getting older, what keeps them going when they get discouraged and feel helpless, etc. This section can help determine what the client wants when they cannot speak for themselves. What is their view on dying, for example are they okay with life support, etc.

h. Financial Factors:

The first question that will be asked is the client’s source of income which could be their pension, social security, etc. and the client’s monthly income. This will help the client and you determine if they can afford someone from the outside and when it comes time for placement if you go for assisted living what is going to be in the client’s budget. Fill in clients assets (e.g. house). Who handles the finances? Are there any financial concerns? The insurance information is very important. Does the client have Medicaid, supplemental insurance, life insurance, etc.? Next you will be asked does the client have a guardian, power of attorney, and legal concerns and if so list those legal concerns (e.g., living will). The gerontologist care manager will answer the client/family perception of problems based on the two to three hour interview with the family.  The gerontologist will then fill out the summary of assessment and recommendations. Recommendations will include financial recommendations, legal recommendations, medical recommendations, psychological recommendations, etc. However, individuals who cannot afford a care manager may be filling out these questions for their client/loved one themselves and it is important to be as honest as possible when answering the above questions.

i. Recommended Plan of care:

What do you see as the problem (e.g. being alone)? What is the goal (e.g. having someone check in on a regular basis, know the neighbors, etc.)? You can have the care manager interview and hire the caregiver.