InterRai HC Assessment

L2. Prior Pressure Ulcer

. a history of pressure ulcers, which is a risk factor for the development of pressure ulcers in the future. Coding 0. No 1. Yes

J9. Tobacco and Alcohol

0. No 1. Not in last 3 days, but is usually a daily smoker 2. Yes

A14. Time Since Last Hospital Stay

0. No hospitalization within 90 days 1. 31 to 90 days ago 2. 15 to 30 days ago 3. 8 to 14 days ago 4. In the last 7 days 5. Now in hospital

M2. Allergy to Any Drug

0. No known drug allergies 1. Yes

A12. Residential/Living Status at Time of Assessment

1. Private home/apartment/rented room 2. Board and care 3. Assisted living or semi-independent living 4.Mental health residence 5. Group home for persons with physical disability 6. Setting for persons with intellectual disability 7. Psychiatric hospital or unit 8. Homeless (with or without shelter) 9. Long-term care facility (nursing home) 10. Rehabilitation hospital/unit — 11. Hospice facility/palliative care unit — 12. Acute care hospital 13. Correctional facility

Significant change in status reassessment

A comprehensive reassessment conducted at any time during the uninterrupted course of care because the person's status or condition has significantly changed. If the change in status is accompanied by a hospital stay, code ―3 for ―Return assessment‖ instead

Routine reassessment —

A regularly scheduled follow-up assessment to ensure that the care plan is appropriate and current.

Section A Identification Information

A1. Name A2. Gender A3. Birthdate A4. Marital Status A5. National Numeric Identifier [Country Specific A5a. Social Security number A5b. Medicare number (or comparable railroad insurance number) — A6. Facility/Agency Provider Number A7. Current Payment Sources A8. Reason for Assessment

G2. ADL Self-Performance

ADL self-performance — Measures based on all episodes of the activity over the last 3 days. The following are the performance-based items. G2a. Bathing — How the person takes a full-body bath or shower. Includes how person transfers in and out of tub or shower and how each part of body is bathed: arms, upper and lower legs, chest, abdomen and perineal area. EXCLUDE WASHING OF BACK AND HAIR. G2b. Personal hygiene — How the person manages personal hygiene, including combing hair, brushing teeth, shaving, applying make-up, washing and drying face and hands. EXCLUDE BATHS AND SHOWERS. G2c. Dressing upper body — How the person dresses and undresses (street clothes, underwear) above the waist, including prostheses, orthotics, fasteners, pullovers, etc. G2d. Dressing lower body — How the person dresses and undresses (street clothes, underwear) from the waist down, including prostheses, orthotics, belts, pants, skirt, shoes, fasteners, etc. G2e. Walking — How the person walks between locations on the same floor indoors. G2f. Locomotion — How the person moves between locations on the same floor (walking or wheeling). If the person uses a wheelchair, this measures self-sufficiency once he or she is in the chair. G2g. Transfer toilet — How the person moves on and off the toilet or commode. G2h. Toilet use — How the person uses the toilet room (or commode, bedpan, urinal), cleanses him- or herself after toilet use or incontinent episode(s), changes bed pad, manages ostomy or catheter, adjusts clothes. This item does not include transfer on and off the toilet. G2i. Bed mobility — How the person moves to and from a lying position, turns from side to side, and positions his or her body while in bed. G2j. Eating — How the person eats and drinks (regardless of skill). Includes intake of nourishment by other means (such as tube feeding or total parenteral nutrition). Coding 1.Setup help — Assistance characterized by the provision of articles, devices, or preparation necessary for the person's self-performance of an activity. This includes giving or holding out an item the person takes from the helper, if the helper then leaves the person alone to complete the activity. . If someone remains nearby to watch over the person, the person is receiving oversight, thus the score would be ―2‖ for ―Supervision. Following are a few examples of setup help. For the ―Personal hygiene‖ item, setup help might mean providing a washbasin or grooming articles. For ―Walking‖, it might take the form of handing the person a walker or cane. For ―Toilet use‖, it might be handing the person a bedpan or placing within reach the articles necessary for changing an ostomy appliance. For ―Eating‖, setup help might include cutting meat or opening containers at meals, carrying a tray to the table, or giving one food categories at a time. Weight bearing — Persons require varying degrees of physical assistance to complete ADL tasks. A key concept in scoring the degree of assistance is the degree of weight-bearing support provided. Guiding movements with minimal physical contact and contact guarding with intermittent physical assistance are not considered weight When ADL self-performance in an area varies over the last 3 days, identify the three most dependent episodes

. First assessment —

An assessment that is done at the time of entry into the home care system, or when initially determining eligibility for home care/home health services.

C4. Acute Change in Mental Status from Person's Usual Functioning

Any sudden or recent change in the person's usual level of functioning; such changes may include restlessness, lethargy, being difficult to arouse, or altered environmental perception. Coding 0. No 1. Yes

L5. Skin Tears or Cuts (Other Than Surgery)

Any traumatic break in the skin penetrating to the subcutaneous tissue. Does not include surgical incisions. Coding Code for the appropriate response. 0. No 1. Yes

H4. Pads or Briefs Worn

Any type of absorbent, disposable or reusable undergarment or item, whether worn by the person (for example, a diaper or adult brief) or placed on the bed or chair for protection from incontinence. Does not include the routine use of pads on beds when the person is never or rarely incontinent. Coding 0. No 1. yes

8. Self-Reported Health

Ask the person: ―In general, how would you rate your health?‖ Record the person's response according to one of the categories below Coding 0. Excellent 1. Good 2. Fair 3. Poor 8. Could not (would not) respond

Section E Mood and Behavior

Associated factors include poor adjustment to one's living situation, functional impairment, resistance to daily care, inability to participate in activities, social isolation, increased risk of medical illness, cognitive impairment, and an increased sensitivity to physical pain.

Section B Intake and Initial History

B1. Date Case Opened ( year, moth , day) B2. Ethnicity and Race B3. Primary Language B4. Residential History over Last 5 Years

J3. Problem Frequency

Balance J3a. Difficult or unable to move self to standing position unassisted J3b. Difficult or unable to turn self around and face the opposite direction when standing J3c. Dizziness — The person experiences a sensation of unsteadiness, that he or she is turning, or that the surroundings are whirling around 3d. Unsteady gait — A gait that places the person at risk of falling Cardiac or Pulmonary J3e. Chest pain — The person experiences any type of pain in the chest area, which may be described as burning, pressure, stabbing, vague discomfort, etc. J3f. Difficulty clearing airway secretions — In the last 3 days the person reports being unable, or has been observed to be unable, to cough effectively to expel respiratory secretions Psychiatric J3g. Abnormal thought process — When the person is observed, there are apparent abnormalities in the form or way in which the person is expressing thoughts. The person jumps from one topic to another without an apparent connection between the topics. Thought blocking — The person suddenly stops in the middle of a sentence and is unable to recover what he or she intended to say or to complete other thoughts. Flight of ideas — The person's thoughts are expressed so quickly that the listener has difficulty keeping up. Tangentiality — The person digresses from the subject under discussion and introduces thoughts that seem unrelated, oblique, or irrelevant. Circumstantiality — The person exhibits lack of goal-directedness, incorporates unnecessary details, and has difficulty getting to an end point int he conversation. Clang association — The connection between the person's thoughts is tenuous. The person may use rhyming and punning in his or her speech. Incoherence — The person's speech is unclear or confused. The communication does not make sense to the intended listener. Neologism — The person makes up a word, which may be condensed from several words. Neologisms are unintelligible to the listener. Punning — The person uses words that are similar in sound, but different in meaning. Delusions — Fixed, false beliefs not shared by others that the person holds even when there is obvious proof or evidence to the contrary. Hallucinations — The person has false perceptions that occur in the absence of any real stimuli Neurological J3j. Aphasia — A speech or language disorder caused by disease or injury to the brain resulting in difficulty expressing thoughts (speaking or writing) or difficulty understanding spoken or written language GI Status J3k. Acid Reflux — The regurgitation of small amounts of acid from the stomach to the throat . J3l. Constipation — No bowel movement in 3 days, or difficult passage of hard stool. J 3m. Diarrhea — The frequent elimination of watery stools, regardless of cause. J3n. Vomiting — Regurgitation of stomach contents, regardless of etiology (for example, drug toxicity, influenza, psychogenic J3n. Vomiting — Regurgitation of stomach contents, regardless of etiology (for example, drug toxicity, influenza, psychogenic

Section C Cognition

Choosing items of clothing Knowing when to eat meals Knowing and using space in the home appropriately Using environmental cues (such as clocks or calendars) to organize and plan the day In the absence of environmental cues, seeking information appropriately (i.e., not repetitively) from family in order to plan the day Using awareness of one's own strengths and limitations in regulating the day's events (for example, asking for help when necessary) Making prudent decisions concerning how and when to go out of the house; where applicable, acknowledging the need to use a walker or other assistive device and using it faithfully The inquiry should focus on whether the person is actively making decisions about how to manage tasks of daily living, and not whether the caregiver believes that the person might be capable of doing so. Remember that the intent of this item is to record what the person is doing (actual performance). CODING : 0. Independent — The person's decisions in organizing daily routines and making decisions were consistent, reasonable, and safe (reflecting lifestyle, culture, values). 1. Modified independence — The person organized daily routines and made safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations only. 2. Minimally impaired — In specific recurring situations, decisions were poor or unsafe, with cues/supervision necessary at those times. 3. Moderately impaired — The person's decisions were consistently poor or unsafe; the person required reminders, cues, or supervision at all times to plan, organize, and conduct daily routines. 4. Severely impaired — The person never (or rarely) made decisions. 5. No discernable consciousness, coma — The person is nonresponsive. (Skip to Section G.)

Capacity

Code based on the person's presumed ability to carry out the activity.This requires speculation by the assessor. 0. Independent — No help, setup, or supervision needed. 1. Setup help only 2. Supervision — Oversight/cuing required. 3. Limited assistance — Help required on some occasions. 4. Extensive assistance — Help required throughout task, but performs 50% or more of task on own. 5. Maximal assistance — Help required throughout task, but performs less than 50% of task on own. 6. Total dependence — Full performance of activity during entire period by others. 8. Activity did not occur — During entire period. NOTE: You may use this code to score the Performance category, but do not use it to score Capacity category

H2. Urinary Collection Device (Excludes Pads/Briefs)

Coding 0. None 1. Condom catheter 2. Indwelling catheter 3. Cystostomy, nephrostomy, ureterostomy

Section S Discharge

Enter the date of the last day of the person's participation in your home care agency, home services, or other health care services. If the month or day contains only a single digit, fill the first box with a ―0

G4a. Total hours of exercise or physical activity in the LAST 3 DAYS (e.g., walking)

Exercise or physical activity — Any exercise that involves at least moderate physical activity, such as walking outdoors, swimming, yoga, class, exercise with machines. Coding If the accumulated time is between 2 hours and 3 hours, use code ―2‖. Hours of exercise do not have to occur all at once on a given day; they may be accumulated over the course of several instances . 0. None 1. Less than 1 hour 2. 1-2 hours 3. 3-4 hours 4. More than 4 hours G4b. In the LAST 3 DAYS, number of days went out of the house or building in which he/she resides Definition Went out of the house or building — This means the person went outdoors, no matter how short the period of time he or she spent outdoors. This could mean going into the yard, standing on an open porch, or walking down the street. Process Ask the person or family if the person went outside in the last 3 days. Coding If illness or weather did not permit (for example, if it snowed or there was a ―tropical‖ downpour) and the person did not leave the house, but normally would have during a 3-day period, use code ―1‖. 0. No days out 1. Did not go out in last 3 days, but usually goes out over a 3-day period 2. 1-2 days 3. 3 days

Section F Psychosocial Well-Being

F1. Social Relationship F1a. Participation in social activities of long-standing interest — The person engaged in social activities that have been of long-standing interest him. Examples include attending meetings of informal clubs or religious services, playing bridge or bingo, volunteering at the local clothing bank, or gossiping with the neighbors on their front porches in the evening F1b. Visit with a long-standing social relation or family member — The person was visited by (or made a visit to) any family member, friend, or social acquaintance with a long-standing relationship with the person (for example, a neighbor or fellow member of a community organization F1c. Other interaction with long-standing social relation or family member — For example, telephone or e-mail. Through a means other than a face-to-face visit with a family member, friend, or social acquaintance with a long-standing relationship with the person (such as a neighbor or fellow member of a community organization or religious group) F1d. Conflict or anger with family or friends — The person expresses feelings such as abandonment, ingratitude on part of the family, lack of understanding by close friends, or hostility regarding relationships with family or friends. F1e. Fearful of a family member or close acquaintance — The person expresses (verbally or through behavior) fear of a family member or close acquaintance. F1f. Neglected, abused, or mistreated — The person experienced a serious or life-threatening situation or condition that went untreated or not acknowledge. Process Ask the person for his or her point of view. What activities does he or she enjoy participating in? When was the last time he or she was able to participate? Who tends to come to visit, and when was the last time that individual visited? Are there other ways the person contacts family or friends (for example, by telephone or e-mail)? Is the person generally content or unhappy in relationships with family and friends? If the person is unhappy, what specifically is he or she unhappy about? If possible, also talk with family members and friends who visit or have frequent telephone contact with the person. The primary caregiver may have a good sense of who visits or contacts the person. He or she can also describe the most common social activities the person was involved in recently. Coding 0. Never 1. More than 30 days ago . 2. 8 to 30 days ago 3. 4 to 7 days ago 4. In last 3 days 8. Unable to determine NOTE: Score ―8‖ for ―Unable to determine‖ if no information is available from the person or other informants about the person's social relationships. .

Section G Functional Status

G1a. Meal preparation -if the person is able to make cold cereal for breakfast, or put together a cold sandwich and drink coffee at lunch, or make toast for dinner without assistance, the person would be scored as independent in meal preparation capacity Assessor: Do you prepare your own meals? For example, do you plan your meals, gather ingredients together, cook, and lay out your food utensils G1b. Ordinary housework —doing dishes, dusting, making bed, tidying up, laundry Managing finances —How bills are paid, checkbook is balanced, household expenses are budgeted, and credit card account is monitored Managing medications — How medications are managed (for example, remembering to take medicines, opening bottles, taking correct drug dosages, giving injections, applying ointment Stairs — How a full flight of stairs is managed (i.e., 12-14 stairs). If the person is able to go up and down only a half flight (2-6 stairs), do not score as independent. G1g. Shopping — How shopping is performed for food and household items (selecting items, paying money). This item does not include transportation G1h. Transportation — How person travels by public transportation (navigating system, paying fare) or drives self (including getting out of the house, into and out of vehicles). Question the person about his or her performance of normal activities around the home or in the community in the last 3 days. You may also talk to family members if they are available Coding Each item should be scored in two categories: Performance and Capacity

ADL Self-Performance scoring rules.

If all episodes in the last 3 days were performed at the same support level, score the ADL at that level. o Note that regarding the scores ― 0‖ (―Independent‖), ― 6‖ (―Total dependence‖), and ― 8‖ (―Activity did not occur‖), this is the only situation in which such a score would apply. In other words, to receive one of these scores, all performance episodes must be at the same level. o Also note that this rule applies when there was only one performance episode during the 3-day period. For example, if over the course of the 3 days the person moved once between locations on the same floor but was bed-bound for the remainder of the time, then the score for Item G2f (―Locomotion‖) should be based on the single episode when the person moved. If any episodes were at level ―6‖ (―Total dependence‖) and other episodes were less dependent, the item should be scored ―5‖ (―Maximal assistance‖). Otherwise, focus on the three most dependent episodes (or the two most dependent episodes if the ADL was only performed twice). If the most dependent of these episodes would be scored ―1‖ for ―Independent, setup help only‖, score the item ―1‖. If the most dependent of these episodes would receive a higher score, however, the item should receive the score to match the least dependent of those episodes in the range between ―2‖ and ―5‖. In accordance with these rules and the guidelines below, enter the number corresponding to the most correct response. CODING 0. Independent — No physical assistance, setup, or supervision in any episode. 1— Article or device provided or placed within reach, no physical assistance or supervision in any episode. 2. Supervision — Oversight/cuing. 3. Limited assistance — Guided maneuvering of limbs, physical guidance without taking weight. 4. Extensive assistance — Weight-bearing support (including lifting limbs) by one helper where person still performs 50% or more of subtasks. 5. Maximal assistance — Weight-bearing support (including lifting limbs) by two or more helpers; or, weight-bearing support for more than 50% of subtasks. 6. Total dependence — Full performance by others during all episodes. 8. Activity did not occur during entire period — Do not confuse a person's total dependence in an ADL activity (―6‖ for ―Total dependence‖) with nonoccurrence of the activity itself (―8‖). For example, even a person who receives tube feedings and no food or fluids by mouth is engaged in eating (receiving nourishment) and must be evaluated under the eating category for his or her level of assistance in the process. A person who is highly involved in giving him- or herself a tube feeding is not totally dependent and should not be scored with ―6‖, but with a lower score, dependent on the nature of the help received from others Record what is actually happening. Remind these persons that the focus is on the last 3 days only. To clarify your own understanding and observations about each ADL activity

L7. Foot Problems

Includes bunions, hammertoes, overlapping toes, structural problems, infections, and ulcers. Coding Code for the appropriate response. 0. No foot problems 1. Foot problems, no limitation in walking 2. Foot problems limit walking 3. Foot problems prevent walking 4. Foot problems, does not walk for other reason

5. Physically Restrained

Indicate whether the person was physically restrained in the last 3 days, regardless of stated intent of restraint Code; 0. No 1. yes

Section J Health Conditions

J1. Falls Any unintentional change in position where the person ends up on the floor, ground, or other lower level; includes falls that occur while being assisted by others. Coding 0. No fall in last 90 days 1. No fall in last 30 days, but fell 31-90 days ago 2. One fall in last 30 days 3. Two or more falls in last 30 days J2. Recent Falls Fall — Any unintentional change in position where the person ends up on the floor, ground, or other lower level; includes falls that occur while being assisted by others. Coding 0. No fall in last 30 days 1. Yes, fall in last 30 day

Sleep Problems

J3o. Difficulty falling asleep or staying asleep; waking up too early; restlessness; nonrestful sleep — J3p. Too much sleep — An excessive amount of sleep that interferes with the person's normal functioning. J3q. Aspiration — The inhalation of food or fluid into the person's lungs.

J3s. GI or GU bleeding

J3s. GI or GU bleeding — ―Gastrointestinal (GI) bleeding‖ is any documented bleeding as diagnosed

J7. Instability of Condition

J7a. Conditions/diseases make cognitive, ADL, mood, or behavior patterns unstable (fluctuating, precarious, or deteriorating) — For example, the person may have a condition such as ulcerative colitis, rheumatoid arthritis, or multiple sclerosis that causes pain or impairs mobility or sensation, resulting in increased dependence on others and depression. J7b. Experiencing an acute episode or a flare-up of a recurrent or chronic problem — The person is symptomatic for an acute health condition (such as new myocardial infarction, adverse drug reaction, or influenza) or recurrent acute condition (such as aspiration pneumonia or urinary tract infection J7c. End-stage disease, 6 or fewer months to live Coding 0. No 1. Yes

F5. Major Life Stressors in Last 90 Days

Life stressors — Experiences that either disrupted or threatened to disrupt a person's daily routine and that imposed some degree of readjustment. Process Ask the person if any stressful events have occurred in the last 90 days. Examples may include an episode of severe personal illness, the death or severe illness of a close family member or friend, the loss of the person's home, a major loss of income or assets, being the victim of a crime such as robbery or assault, the loss of the person's driving license or car, etc . Coding 0. No 1. Yes

L4. Major Skin Problems

Major skin problems — This item includes lesions, second- or third-degree burns, and healing surgical wounds. Burn — Injury to tissues resulting from thermal, electrical, chemical, or radioactive exposure. The effect of the injury may be local or systemic. Coding Code for the appropriate response. 0. No 1. Yes

K2. Nutritional Issues

Marked, unintended declines in weight can indicate failure to thrive; a sign of a potentially serious medical problem; or poor nutritional intake due to physical, cognitive, or social factors Weight loss of 5% or more in LAST 30 DAYS, or 10% or more in LAST 180 DAY Dehydrated or BUN/creatinine ratio > 25 Fluid intake less than four 8 oz cups per day (or less than 1,000 cc per day) Fluid output exceeds input

Section M Medications

Medications — These include all prescribed, nonprescribed, and over-thecounter medications that the person consumed in the last 3 days. Medications may be taken by mouth, placed on the skin or in the eyes, injected, given intravenously, etc. This includes prescriptions now discontinued but taken in the last 3 days and drugs prescribed PRN (as needed) that were taken during this period. It also includes medications that are prescribed on a maintenance schedule, such as vitamin injections given once a month, even if they were not given in the last 3 days.

G4. Activity Level

Moderate physical activity in connection with activities of everyday life or chosen activities can help to keep persons in home care fit in many ways. Below a certain threshold of activity, functional decline may be accelerated. It is necessary to understand whether the person is motivated to undertake physical activity, what the person's needs may be, what barriers need to be overcome, and whether health education is needed

N4. Hospital Use, Emergency Room Use, Physician Visit in Last 90 Days (or Since Last Assessment if Less Than 90 Days Ago)

N4a. Inpatient acute hospital with overnight stay The person was formally admitted as an inpatient (by physician's order), and stayed over 1 or more nights. It does not include admissions for day surgery, outpatient services, etc N4b. Emergency room visit (not counting overnight stay) N4c. Physician visit (or authorized assistant or practitioner) Coding Enter the number of visits with a physician or authorized assistant or practitioner during the last 90 days (or since the last assessment, if the person was assessed less than 90 days ago). If there were no such visits, enter ―0‖

J6. Pain Symptoms

NOTE: Always ask the person about frequency, intensity, and control of the pain. Observe the person and ask others who are in contact with the person Pain — ―An unpleasant sensory and emotional experience‖ that is generally associated with actual or potential tissue damage. Pain is highly subjective. Frequency with which person complains or shows evidence of pain — Including grimacing, teeth clenching, moaning, withdrawal when I1 touched, or other nonverbal signs suggesting pain. Coding 0. No pain 1. Present but not exhibited in last 3 days 2. Exhibited on 1-2 of last 3 days 3. Exhibited daily in last 3 days Intensity of highest level of pain present — The level of pain reported by or observed in the person. Coding 0. No pain 1. Mild 2. Moderate 3. Severe 4. Times when pain is horrible or excruciating J6c. Consistency of pain — Measures the frequency (ebb and flow) of pain from the person's perspective. Coding 0. No pain 1. Single episode during last 3 days 2. Intermittent t 3. Constant J6d. Breakthrough pain — The person experienced a sudden, acute flare-up of pain one or more times in the last 3 days. Breakthrough pain might appear as a dramatic increase in the level of pain above that addressed by ongoing analgesics, or the recurrence of pain associated with end-ofdose failure. Coding 0. No 1. Yes J6e. Pain control — The ability of the current therapeutic regimen to control the person's pain adequately (from the person's point of view). This item describes the adequacy or inadequacy of pain control measures (such as medications, massage, TENS, or other therapeutic regimen) instituted by the person, caregiver, or clinical staff caring for the person, Coding 0. No issue of pain 1. Pain intensity acceptable to person, no treatment regimen or change in regimen required 2. Controlled adequately by therapeutic regimen 3. Controlled when therapeutic regimen followed, but not always followed as ordered 4. Therapeutic regimen followed, but pain control not adequate 5. No therapeutic regimen being followed for pain; pain not adequately controlled

C2. Memory/Recall Ability

NOTE: If the person received a score of ―5‖ (―No discernable consciousness, coma‖) on Item C1, do not complete Items C2-C5 or any of the items in Section D, Section E, or Section F. Instead, proceed directly to Section G. C2a. Short-term memory OK — Seems, appears to recall after 5 minutes. C2b. Procedural memory OK — Can perform all or almost all steps in a multitask sequence without cues. C2c. Situational memory OK — Both recognizes the names/faces of caregivers frequently encountered and knows the location of places regularly visited (bedroom, kitchen, etc.). CODING: 0. Yes Memory OK 1. Memory problem

Section O Responsibility

O1. Legal Guardian

Section R Discharge Potential and Overall Status One or More Care Goals Met in the Last 90 Days (or Since Last Assessment if Less Than 90 Days Ago

One or More Care Goals Met in the Last 90 Days (or Since Last Assessment if Less Than 90 Days Ago Code 0. No 1. yes Overall Self-Sufficiency Has Changed Significantly as Compared to Status of 90 Days Ago (or Since Last Assessment if Less Than 90 Days Ago) Intent To monitor the person's overall self-sufficiency in the community over time. If this is the person's first assessment, include changes during the period prior to admission to the service agency. Record the number corresponding to the most correct response. If the score is ―0‖ or ―1‖, you should then proceed directly to Section S; if the score is ―3‖, complete the remainder of Section R before moving on to Section S. 0. Improved (Skip to Section S) 1. No change (Skip to Section S 2. Deteriorated R3. Number of 10 ADL Areas in Which Person Was Independent Prior to Deterioration Definition 10 ADL areas — See Item G2 for the complete list of activities of daily living (ADLs), beginning with ―Bathing‖ (G2a) and ending with ―Eating‖ (G2j). Coding Enter the number of ADLs in which the person was independent before the deterioration that occurred during the assessment period. If the number is a single digit, use a leading zero to fill in the first box. R4. Number of 8 IADL Performance Areas in Which Person Was Independent Prior to Deterioration Definition 8 IADL areas — See Item G1 for the complete list of instrumental activities of daily living (IADLs), beginning with ―Meal preparation‖ (G1a) and ending with ―Transportation‖ (G1h). Coding Enter the number of IADLs in which the person was independent before the deterioration that occurred during the assessment period. R5. Time of Onset of the Precipitating Event or Problem Related to Deterioration Coding 0.Within last 7 days 1. 8 to 14 days ago 2. 15 to 30 days ago 3. 31 to 60 days ago 4. More than 60 days ago 8. No clear precipitating even

Section P Social Supports

P1. Two Key Informal Helpers To assess the person's informal caregiver support system. This is different from a formal relationship that the person may have with a home care agency Helper 1 — This is the primary informal helper, who may be a family member, friend, or neighbor, but not a paid service provider. Helper 2 — This is the secondary informal helper, the individual whom, after the primary helper, the person most relies on to help or give advice and counsel when needed. Coding 1. Child or child-in-law 2. Spouse 3. Partner/significant other 4. Parent/guardian 5. Sibling 6. Other relative 7. Friend 8. Neighbor 9. No informal helper P1b. Lives with person To assess whether the person lives with the informal helper(s), and the duration of the living arrangement. Definition An informal helper is said to live with the person if the person and helper share the same space (house, apartment/flat). This does not include living in an adjacent or neighboring apartment/flat/house. Coding For both columns (Helper 1 and Helper 2), use the following codes. 0. No 1. Yes, 6 months or less 2. Yes, more than 6 months 8. No informal helper Areas of Informal Help During the Last 3 Day For each column (Helper 1 and Helper 2), code ―Yes‖ if the helper is assisting the person with IADLs 1. IADL 0. No 1. yes 2. ADL ) 0. No 1. yes P2. Informal Helper Status P2a. Informal helper(s) is (are) unable to continue in caring activities 2b. Primary informal helper expresses feelings of distress, anger, or depression 2c. Family or close friends report feeling overwhelmed by person's illness Coding ) 0. No 1. yes P3. Hours of Informal Care and Active Monitoring During Last 3 Days Record the total amount of help the person received from family, friends, or neighbors over the last 3 days. For example, if family members, friends, and neighbors provided 120 minutes (2 hours) each day, the total number of hours for help received during the last 3 days is 6. If more than one individual provided help, at the same time or at different times, add up the hours for each individual—for example, if two neighbors spent an hour together doing housecleaning for the person, this would count as 2 hours.

Item-by-Item Guide to the interRAI Home Care (HC)

Section A. Identification Information Section B. Intake and Initial History Section C. Cognition Section D. Communication and Vision Section E. Mood and Behavior Section F. Psychosocial Well-Being Section G. Functional Status H. Continence Section I. Disease Diagnoses Section J. Health Conditions Section K. Oral and Nutritional Status Section L. Skin Condition Section M. Medications Section N. Treatments and Procedures Section O. Responsibility Section P. Social Supports Section Q. Environmental Assessment Section R. Discharge Potential and Overall Status Section S. Discharge 105 Section T. Assessment Information 107

Section T Assessment Information

Signature of Person Coordinating/Completing the Assessment

A10. Person's Expressed Goals of Care

Talk to the person and phrase your questions about goals of care in the most general way possible. For example, ask: ― How can we help you?‖ ― Why are you getting (or applying for) services?‖ ―What benefits do you expect to get?‖ ―What changes in yourself do you hope will occur? ‖ Encourage the person to express personal goals in his or her own words. Some persons will be unable to articulate a goal, an expected outcome, or even a reason for seeking services

K3. Mode of Nutritional Intake

The ability to swallow safely can be affected by many disease processes and by functional decline. Alterations in one's ability to swallow could result in choking and aspiration, both of which can cause morbidity and mortality Coding 0. Normal — Person swallows all types of foods. 1. Modified independent — For example, liquid is sipped, or person takes limited solid food; need for modification may be unknown. 2. Requires diet modification to swallow solid food — For example, mechanical diet (puree, minced, etc.) is required, or person is only able to ingest specific foods. 3. Requires modification to swallow liquids — For example, liquids must be thickened. 4. Can swallow only pureed solids AND thickened liquids 5. Combined oral and parenteral or tube feeding 6. Nasogastric tube feeding only 7. Abdominal feeding tube — For example, a PEG tube. 8. Parenteral feeding only — Includes all types of parenteral feedings, such as total parenteral nutrition (TPN). 9. Activity did not occur — Person did not eat or receive any form of nutritional supplementation during the last 3 days. K4. Dental or Oral Intent To record any oral problems present in the last 3 day

F3. Change in Social Activities in Last 90 Days

The level of participation refers to the quantity (how many) of different types of social activities; the intensity (how frequently contact occurs); and the quality of the activity (how deeply the person is involved). Remote participation is equally important and significant for the person's role fulfillment and selfesteem (for example, a person who cannot move outside his or her home may still participate or be associated with some kind of religious, political, or social activity). Distress occurs when the person's mood is adversely affected by a recent change in the level of participation (as evidenced by sadness, loss of motivation or self-esteem, anxiety, or depression, for example). Process Talk with the person to determine whether a change has occurred and to determine his or her subjective response to any changes. If possible, speak with the family or other informal contacts (such as neighbors) to get their opinions on whether the person's activity levels have changed and, if so, how he or she responded to those changes. Coding : 0. No decline — There was no change or there was an increase in the person's level of participation in social activities. 1. Decline, not distressed — The person experienced a decline in his or her level of participation in social activities without a corresponding increase in his or her distress . 2. Decline, distressed — Both decline and distress are observed or reported

J3u. Peripheral edema

The person has an abnormal buildup of fluid in foot/ankle/leg tissue Coding 0. Not present 1. Present but not exhibited in last 3 days 2. Exhibited on 1 of last 3 days 3. Exhibited on 2 of last 3 days 4. Exhibited daily in last 3 days

J4. Dyspnea (Shortness of Breath

The person has reported being, or has been observed to be, breathless or ―short of breath.‖ Code for the most severe occurrence during the last 3 days. If the symptom was absent over the last 3 days, but would have been present had the person undertaken activity, code according to the activity level (day-to-day or moderate) that would normally have caused the person to experience shortness of breath. ― Moderate activities‖ include some type of physical exercise, such as walking a long distance, climbing 2 flights of stairs, or gardening. ―Normal day-today activities‖ include all ADLs (bathing, transferring, etc.) and IADLs (meal preparation, shopping, etc.). 0. Absence of symptom 1. Absent at rest, but present when performed moderate activities 2. Absent at rest, but present when performed normal day-to-day activities 3. Present at rest

P4. Strong and Supportive Relationship with Family

The person indicates he or she has a supportive relationship with family members. The person may feel able to ―rely on‖ family members. Family members may be actively involved in the person's physical care, maintaining the household, managing finances, or helping the person make medical decisions. Coding 0. No 1. yes

M3. Adherent with Medications Prescribed by Physician

The person is actually taking medications as prescribed 0. Always adherent 1. Adherent 80% of time or more — Over the last 3 days, 24 hours a day, the person deviated from prescribed medication regime 20% or less of the time. 2. Adherent less than 80% of the time, including failure to purchase prescribed medications — Over the last 3 days, 24 hours a day, person deviated from prescribed medication regime more than 20% of the time. 8. No medications prescribed — Person is not receiving any prescribed medication

F2. Lonely

The person states or otherwise indicates that he or she feels lonely. The person may feel that others do not visit enough or desire more social interaction even if visited regularly. Others may also report that the person sometimes comments on feeling lonely. Process Talk with the person to determine whether or not he or she feels lonely. If possible, speak with the person's family or other informal contacts (such as neighbors) to get their perception of the person's feelings of loneliness Coding 0. No 1. Yes

Section N Treatments and Procedures

This item helps home care workers to identify whether the person has unmet needs for health counseling and preventive care. . Blood pressure measured in LAST YEAR Colonoscopy test in LAST 5 YEARS — The entire colon (from anus to cecum) Eye exam in LAST YEAR . Hearing exam in LAST 2 YEARS Influenza vaccine in LAST YEAR — Mammogram or breast exam in LAST 2 YEARS ( Pneumovax vaccine in LAST 5 YEARS or after age 65 Code the appropriate response. 0. No 1. Yes

N2. Treatments and Programs Received or Scheduled in the Last 3 Days (or Since Last Assessment if Less Than 3 Days

This item includes special treatments, therapies, and programs received or scheduled during the last 3 days or since last assessment if less than 3 days have passed), as well as adherence to the required schedule. It includes services received in the home or on an outpt. basis. treatments: Chemo Dialysis Infection control IV medication Oxygen Theraphy Radiation Suctioning Tracheaostomy care Transfusion Ventilator Wound Care Schedule toileting program Palliative care Turning/reposition 0. Not ordered AND did not occur 1. Ordered, not implemented 2. 1-2 of last 3 days 3. Daily in last 3 days

G3b. Timed 13-foot (or 4-meter) wal

This performance test provides a measure of the person's stamina. It is designed to establish an objective benchmark for comparison with the person's performance upon subsequent reassessments This test cannot be done with persons who need any type of physical weightbearing assistance to walk. For persons who need this type of assistance, use the score ―99‖ for ― Not tested‖. If the person is capable of doing the test but chooses not to, enter ―88‖ for ―Refused to do the test‖. For persons who do the test, use the scoring guidelines that follow. If the person completes the test in less than 30 seconds, enter the number of seconds. (If fewer than 10 seconds, use a leading zero to fill in the first box—for example, ―09‖.) If the person took 30 or more seconds to complete the test, enter ―30‖ as the score. If the person began the test but did not finish it, enter ―77‖ for ―Stopped befoe test complete

G3c. Distance walked

To assess the person's independence in walking around the home or the community. Definition Farthest distance walked at one time without sitting down in the last 3 days, with support as needed. Process Ask the person and family member about the person's walking in the home or community during the last 3 days. Record the farthest distance walked without sitting down. Coding 0. Did not walk 1. Less than 15 feet (under 5 meters) 2. 15-149 feet (5-49 meters) 3. 150-299 feet (50-99 meters) 4. 300+ feet (100+ meters) 5. ½ mile or more (1+ kilometer

N3. Formal Care — Days and Total Minutes of Care in Last 7 Days

To capture the number of minutes spent by formal caregiving agencies in providing care or care management in the last 7 days (or since the last assessment or admission, if less than 7 days have passed). Definitions Care — Includes direct services provided to the person (both ADL and IADL support), the management of care received (for example, making medication schedules, planning for future needs), and the provision of therapeutic care by any formal agency or service provider. Home Health Aide - ADL support Home Nurse Homemaking services -IADL Meals PT OT ST Audiology Psychological therapy Code the number of days in the first column (maximum = 7) and the number of minutes in the second column, one digit per box. Based on the information available to you, select the best category for the type of support provided. Do not code twice for the same service. If the agency did not provide a particular form of care, enter ―0‖ in the appropriate box(es). Do not code for care that the person received privately

C5. Change in Decision Making as Compared to 90 Days Ago (or Since Last Assessment if Less Than 90 Days Ago

To compare the person's current decision-making ability to that of 90 days ago (or since the last assessment, if that was less than 90 days ago). The changes may be permanent or temporary, and the cause may be known (for example, psychotropic medication or new pain) or unknown. If the person is newly admitted to the program, include changes since admission and changes during the period prior to admission. Process Talk to the person and family members. Ask them to compare the person's decision-making status now versus 90 days ago (or since the last assessment if less than 90 days ago). To help identify the 90-day time period, ask the person or others to pinpoint an event that occurred 3 months ago, and then to relate the person's functioning to that event. For example, if the person visited a family member 3 months ago, ask how able he or she was in making decisions during that trip. Coding 0. Improved .1. No change 2. Declined 8. Uncertain

5. Fatigue

To describe gradations of fatigue or impaired stamina. Fatigue is associated with some chronic diseases and end-stage conditions. Definitions Fatigue — An overwhelming or sustained sense of exhaustion resulting in decreased capacity for physical or mental work. Normal day-to-day activities — Coding Select the appropriate code from the list below. If fatigue was absent over the last 3 days, but would have been present had the person undertaken activity, code according to the activity level that would normally have caused the person to experience fatigue. 0. None 1. Minimal — Diminished energy but completes normal day-to-day activities. 2. Moderate — Due to diminished energy, unable to finish normal day-today activities. 3. Severe — Due to diminished energy, unable to start some normal dayto-day activities. 4. Unable to commence any normal day-to-day activities — Due to diminished energy

D2. Ability to Understand Others (Comprehension)

To describe the person's ability to comprehend verbal information, whether communicated to the person orally, in writing, or through sign language or Braille. This item measures the person's ability not only to hear messages but also to process and understand language. Process Interact with the person. Consult with family. 0. Understands — Clearly comprehends the speaker's 1. Usually understands — With little or no prompting, person misses some part or intent of the message but comprehends most of it. The person may have periodic 2. Often understands — The person misses some part or intent of the message. However, with prompting (repetition or more detailed explanation), the person often comprehends the conversation. 3. Sometimes understands — The person demonstrates frequent difficulties integrating information, and responds adequately only to simple and direct questions or directions. When the message is rephrased or simplified, or gestures are used, the person's comprehension is enhanced. 4. Rarely or never understands — The person demonstrates very limited ability to understand communication, or the assessor cannot determine whether the person comprehends messages, based on his or her verbal and nonverbal responses. Includes situations where the person can hear sounds but does not understand messages.

Section H Continence

To determine and record the person's pattern of bladder continence (control) over the last 3 days. Definition This item describes the person's bladder continence pattern, taking into account any control plans or devices, such as scheduled toileting plans, continence training programs, or urinary appliances. It does not refer to the person's ability to toilet him- or herself—for example, a person may require extensive assistance in toileting and still be continent. Bladder incontinence includes any level of dribbling or wetting of urine Validate continence patterns with people who know the person well (such as family caregivers). Remember to consider continence patterns over the last 3-day period, 24 hours a day, including weekends. Coding 0. Continent — Complete control, including control achieved by cuing or supervision that involves prompted voiding, habit training, reminders, etc. The person does not use any type of catheter or other urinary collection device. 1. Complete control with any catheter or ostomy — Control with use of any type of catheter or urinary collection device. 2. Infrequently incontinent — Not incontinent over last 3 days, but does have incontinent episodes (i.e., a recent history of incontinence). 3. Occasionally incontinent — Less than daily episodes of bladder incontinence (incontinent on 1-2 of the last 3 days). 4. Frequently incontinent — Incontinent daily, but some control present (the person is not incontinent during each episode of urination). Example: During the day, the person remains dry and is continent of urine. At night, the person wets his or her bed 5. Incontinent — No control of bladder; multiple daily episodes all or almost all of the time. 8. Did not occur — No urine output from bladder in last 3 day

J9b. Alcohol

To determine if a person's consumption of alcohol is a potential problem by identifying the highest number of alcoholic drinks the person had in a ―single sitting‖ during the last 14 days. Definitions Alcohol — Includes beer, wine, mixed drinks, liquor, and liqueurs. Single sitting — Refers to any given point in time (for example, at dinner, after work, while out at a social event, watching television). Code for the highest number of drinks ingested by the person at one sitting over the last 14 days. 0. None 1. 1 2. 2-4 3. 5 or more

Section L Skin Condition

To determine the condition of the person's skin, identify the presence and stage of ulcers, document other skin conditions, and note any foot problems that may be present. To record the highest stage of pressure ulcers on any part of the body present in the last 3 day Pressure ulcer — Any lesion caused by unrelieved pressure. Pressure ulcers usually occur over bony prominences and are staged to classify the degree of tissue damage observed. For a chair-bound or bedfast person, conduct a skin examination, paying particular attention to the person's hips, thighs, buttocks, low back, and heels. Coding 0. No pressure ulcer 1. Any area of persistent skin redness — An area of skin that appears continually reddened and does not disappear when pressure is relieved. There is no break in the skin. Also known as ―Stage 1.‖ 2. Partial loss of skin layers — A partial-thickness loss of skin that presents clinically as an abrasion, blister, or shallow crater. Also known as ―Stage 2. ‖ 3. Deep craters in the skin — A full thickness of skin is lost, exposing the subcutaneous tissues. Presents as a deep crater with or without undermining of adjacent tissue. Also known as ―Stage 3.‖ 4. Breaks in skin exposing muscle or bone — A full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone. Also known as ―Stage 4 .‖ 5. Not codable — For example, because necrotic eschar is predominant.

G6. Change in ADL Status as Compared to 90 Days Ago,r Since Last Assessment if Less Than 90 Days Ago

To determine whether the person's current activities of daily living (ADL) status differs from the status of 90 days ago (or since the last assessment, if that was less than 90 days ago). Process Talk to the person. Ask the person to think about how well he or she was able to do ADLs 90 days ago. How does the person's current ADL status compare to 90 days ago? If indicated, talk to a family member or caregiver. Coding Code for the most appropriate category. If there is a change in multiple domains, code for the overall direction of change. 0. Improved 1. No change 2. Declined 3. Uncertain

Section D Communication and Vision

To document the person's ability to express or communicate requests, needs, opinions, and urgent problems and to engage in social conversation. Such communication may take the form of speech, writing, sign language, or a combination of these (includes use of word board or keyboard). 0. Understood — The person expresses ideas clearly without difficulty. 1. Usually understood — The person has difficulty finding the right words or finishing thoughts (resulting in delayed responses), but if given time, requires little or no prompting. 2. Often understood — The person has difficulty finding words or finishing thoughts, and prompting is usually required. 3. Sometimes understood — The person has limited ability, but is able to express concrete requests regarding at least basic needs (such as food, drink, sleep, toilet). 4. Rarely or never understood — At best, understanding is limited to interpretation of highly individual, person-specific sounds or body language (for example, caregiver has learned to interpret person signaling the presence of pain or need to toilet).

I1. Diseases

To document the presence of diseases or infections relevant to the person's current ADL status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. Musculoskeletal I1a. Hip fracture during last 30 days (or since last assessment if less than 30 days) — Includes any hip fracture that occurred during the past 30 days (or since the last assessment, if that was less than 30 days ago) that continues to have a relationship to current status, treatments, monitoring, etc. Hip fracture diagnoses also include femoral neck fractures, fractures of the trochanter, and subcapital fx. I1b. Other fracture over last 30 days (or since last assessment if less than 30 days) — Any fracture other than hip bone (for example, wrist) due to any condition, such as falls or weakening of the bone as a result of cancer. Neurological I1c. Alzheimer's disease — A degenerative and progressive dementia I1d. Dementia other than Alzheimer's disease — Includes diagnoses of organic brain syndrome (OBS) or . I1f. Multiple sclerosis — A disease in which there is demyelination throughout the central nervous system. I1h. Parkinson's disease — A disorder of the brain characterized by tremor and difficulty with walking, movement, and coordination. I1i. Quadriplegia — Paralysis (temporary or permanent impairment of sensation, function, motion) of all four limbs and trunk. I1j. Stroke/CVA — A sudden rupture or blockage of a blood vessel within the brain, causing serious bleeding or local obstruction Cardiac or Pulmonary I1k. Coronary heart disease — A chronic condition marked by thickening and loss of elasticity of the coronary artery, and caused by deposits of plaque containing cholesterol, lipoid material, and lipophages. I1l. Chronic obstructive pulmonary disease — Any long-standing condition that impairs airflow in and out of the lungs. I1m. Congestive heart failure — A condition in which the heart cannot pump out all the blood that enters it, which leads to an accumulation of blood in the vessels, fluid in the body tissues, and lung congestion. Psychiatric I1n. Anxiety — A nonpsychotic mental disorder. There are five types, which include: • Generalized anxiety disorder • Obsessive-compulsive disorder • Panic disorder • Phobias • Post-traumatic stress disorder I1o. Bipolar disorder — Includes documentation of clinical diagnosis of either manic depression or bipolar disorder. ―Bipolar disorder‖ is the current term for manic-depressive illness. I1p. Depression — A mood disorder often characterized by a depressed mood (for example, the person feels sad or empty, appears tearful); decreased ability to think or concentrate; loss of interest or pleasure in usual activities; insomnia or hypersomnia; loss of energy; change in appetite; or feelings of hopelessness, worthlessness, or guilt. May also include thoughts of death or suicide. I1q. Schizophrenia — A disturbance characterized by delusions, hallucinations, disorganized speech, grossly disorganized behavior, disordered thinking, or flat affect. Infections I1r. Pneumonia — Inflammation of the lungs, most commonly of bacterial or viral origin. . Urinary tract infection in last 30 days — Includes chronic and acute symptomatic infection(s) in the last 30 days. 11t. Cancer — Any malignant growth or tumor caused by abnormal and uncontrolled cell division. The malignant growth or tumor may spread to other parts of the body through the lymphatic system or the bloodstream. I1u. Diabetes mellitus — Any of several metabolic disorders marked by persistent thirst and excessive discharge of urine Coding 0. Not present 1. Primary diagnosis/diagnoses for current stay — One or more diagnoses that are the main reason(s) used to support and justify services being provided. 2. Diagnosis present, receiving active treatment — Treatment can include medications, therapy, or other skilled interventions such as wound care or suctioning. 3. Diagnosis present, monitored but no active treatment — Person has a diagnosis that is being monitored (for example, with laboratory tests or vital signs), but no active treatment is being provided.

L6. Other Skin Conditions or Changes in Skin Condition

To document the presence of skin problems other than ulcers, skin tears, or cuts and the major skin problems represented in the earlier items. Definitions Other skin conditions or changes in skin condition — For example, bruises, rashes, itching, mottling, herpes zoster, intertrigo, or eczema. Rash — A transient eruption of the skin. Mottling — A condition characterized by areas of skin discoloration. Eczema — Major features include pruritus, atypical morphology and distribution, and a tendency toward dry skin and itching. Flaking of skin may occur. Coding Code for the appropriate response. 0. No 1. Yes

G7. Driving

To evaluate one aspect of community independence and determine whether the person's driving is a concern. Definitions G7a. Drove car (vehicle) in the last 90 days — For example, the person drove to a store, to visit, to a medical appointment. G7b. If drove in LAST 90 DAYS, assessor is aware that someone has suggested that person limits OR stops driving Coding 0, No, or does not drive 1. Yes

D3. Hearing

To evaluate the person's ability to hear (with environmental adjustments, if necessary) during the past 3-day period. Coding: 0. Adequate — No difficulty in normal conversation, social interaction, listen ; . 1. Minimal difficulty — Difficulty in some environments (for example, when the other person speaks softly or is more than 6 feet [2 meters] away). 2. Moderate difficulty — Problem hearing normal conversation, requires quiet setting to hear well. 3. Severe difficulty — Difficulty in all situations (for example, speaker has to talk loudly or speak very slowly, or person reports that all speech is mumbled). 4. No hearing

D4. Vision

To evaluate the person's ability to see close objects in adequate light, using the person's customary visual appliances for close vision (such as glasses or a magnifying glass). Definition Adequate light — What is sufficient or comfortable for a person with normal vision. Process Ask person, family member, or home care staff if the person has manifested any change in usual vision patterns over the past 3 days—for example, is the person still able to read newsprint, greeting cards, and the like? Ask the person about his or her visual abilities. Test the accuracy of your findings by asking the person to look at regular-size print in a book or newspaper with whatever visual appliance he or she customarily uses for close vision (such as glasses or magnifying) Coding : 0. Adequate — The person sees fine detail, including regular print in newspapers/books. 1. Minimal difficulty — The person sees large print, but not regular print in newspapers/books. 2. Moderate difficulty — The person has limited vision; is not able to see newspaper headlines, but can identify objects in his or her environment. 3. Severe difficulty — The person's ability to identify objects in his or her environment is in question, . Also includes the ability to see only light, colors, or shapes. NOTE: Many persons with severe cognitive impairment are unable to participate in vision screening because they are unable to follow directions or are unable to tell you what they see. * However, many such persons appear to ―track‖ or follow moving objects in their environment with their eyes. For persons who appear to do this, score the item ―3‖ for ―Severe difficulty‖. This is often the best assessment you can do with the limited technology available in the home care environment. 4. No vision — The person has no vision; eyes do not appear to be following objects (especially people walking by

F4. Length of Time Alone During the Day (Morning and Afternoon)

To identify the actual amount of time the person is alone. Definition The amount of time the person is literally alone, without any other person in the home. If the person is residing in a board and care facility, congregate housing, or other situation where there are other persons in their own rooms, count the amount of time the person spends by him- or herself in the person's own room as time alone. Process First ask the person how much time he or she spends alone. Be clear about how ― being alone‖ is defined. Confirm with caregivers the amount of time the person spends alone. Coding 0. Less than 1 hour 1. 1-2 hours 2. More than 2 hours but less than 8 hours 3. 8 hours or more

E3. Behavior Symptoms

To identify the frequency of behavioral symptoms during the last 3 days that cause distress to the person, or are distressing or disruptive to others with whom the person lives. Such behaviors include those that are potentially harmful to the person or disruptive to others. ―combative or agitated‖ E3a. Wandering — Moved about with no discernible, rational purpose. A wandering person may be oblivious to his or her physical or safety needs. Wandering behavior should be differentiated from purposeful movement (such as a hungry person moving about the apartment in search of food). Wandering may be by walking or by wheelchair. Do not include pacing back and forth, which is not considered wandering. E3b. Verbal abuse — For example, others were threatened, screamed at, or cursed at. E3c. Physical abuse — For example, others were hit, shoved, scratched, or sexually abused. E3d. Socially inappropriate or disruptive behavior — For example, made disruptive sounds or noises, screamed out, smeared or threw food or feces, hoarded, or rummaged through others' belongings. E3e. Inappropriate public sexual behavior or public disrobing E3f. Resists care — For example, resisted taking medications/injections; pushed caregiver while receiving assistance with ADLs, eating, or changing position. Coding: 0. Not present 1. Present but not exhibited in last 3 days — This code indicates that while the assessor knows the condition is present and active, it was not physically manifested over the last 3 days. 2. Exhibited on 1-2 of last 3 days 3. Exhibited daily in last 3 day

L3. Presence of Skin Ulcer Other Than Pressure Ulcer

To identify the presence of any skin ulcer that is not a pressure ulcer—for example, a venous ulcer, arterial ulcer, mixed venous-arterial ulcer, or diabetic foot ulcer. Definition An open lesion caused by poor circulation in the lower limbs. Coding Select the appropriate response. 0. No 1. Yes

G3d. Distance wheeled self

To monitor a person's independence in moving about the home or community in a nonmotorized wheelchair (or scooter). Definition The farthest distance the person wheeled him- or herself at one time in the last 3 days (includes independent use of motorized wheelchair). Process Ask the person and family member about the person's movement in the home or community during the last 3 days. Record the farthest distance traveled without a prolonged stop. Coding 0. Wheeled by others 1. Used motorized wheelchair/scooter 2. Wheeled self less than 15 feet (under 5 meters) 3. Wheeled self 15-149 feet (5-49 meters) 4. Wheeled self 150-299 feet (50-99 meters) 5. Wheeled self 300+ feet (100+ meters) 8. Did not use wheelchair

K4. Dental or Oral

To record any oral problems present in the last 3 days K4a. Wears a denture (removable prosthesis) — K4b. Has broken, fragmented, loose, or otherwise nonintact natural teeth — The person has natural teeth that are broken, fragmented K4c. Reports having dry mouth — The person reports having a dry mouth or difficulty in moving a food bolus in his or her mouth . K4d. Reports difficulty chewing — The person is unable to chew food easily Ask the person about difficulties in these areas. If possible, observe the person during a meal. Inspect the mouth for abnormalities that could contribute to chewing or swallowing problems or mouth pain. Coding 0. No 1. Yes

C3. Periodic Disordered Thinking or Awareness

To record behavioral signs that may indicate that delirium is present. Frequently, delirium (an acute confusional state) is caused by a treatable illness such as an infection or a reaction to medication. For example, disordered thinking may result in rambling, irrelevant, or incoherent speech. A recent and perhaps rapid deterioration in cognitive function is likely indicative of delirium, which may be reversible if detected and treated .. C3a. Easily distracted — For example, episodes of difficulty paying attention; person gets sidetracked. C3b. Episodes of disorganized speech — For example, speech is nonsensical, irrelevant, or rambling from subject to subject; person loses train of thought. C3c. Mental function varies over the course of the day — Sometimes better, sometimes worse; behaviors sometimes present, sometimes not. Ask the person or others who know the person if any of the behaviors have been noticed over the last 3 days. If the response is yes, determine whether the behavior is different from the person's normal functioning. CODING: 0.Behavior not present 1. Behavior present, consistent with usual functioning 2. Behavior present, appears different from usual functioning — for example, new onset or worsening, different from a few weeks ago.

Section K Oral and Nutritional Status

To record the person's current height and weight in order to monitor nutrition, hydration status, and weight stability over time Record height in inches (Item K1a) and weight in pounds (Item K1b). Base weight on most recent measure in the last 30 days

E2. Self-Reported Mood

To record the person's self-reported mood over the last 3 days. In some cases, the person may deny feeling a particular way in the last 3 days, but reports that the issue continues to be ―present‖ and active. These items involve verbal reports of the person's subjective evaluation three dimensions of mood state (i.e., anhedonia, anxiety, dysphoria) over the last 3 days. ― In the last 3 days, how often have you felt . . .‖ E2a. Little interest or pleasure in things you normally enjoy? E2b. Anxious, restless, or uneasy? E2c. Sad, depressed, or hopeless Only the person's responses should be used to rate each item. Do not record ratings given by family, friends or other . If the person is unable (due to cognitive impairment, for example) or refuses to respond, do not dwell on these items and do not impute responses for the person. Use code ―8‖ in such a situation. Persons unable or unwilling to respond should be scored ―8‖ for ―Person could not (would not) respond‖. Coding: 0. Not in last 3 days 1. Not in last 3 days, but often feels that way — Use this code only if the person indicates the feeling is frequently present and active, but was not experienced in the last 3 days. 2. In 1-2 of last 3 days 3. Daily in the last 3 days 8. Person could not (would not) respond

E1. Indicators of Possible Depressed, Anxious, or Sad Mood

To record the presence of indicators observed in the last 3 days, irrespective of the assumed cause of the indicator/behavior. Definitions The mental state indicators may be expressed verbally through direct statements or through nonverbal indicators or behaviors that can be monitored by observing the person during usual daily routines. E1a. Made negative statements — For example, ―Nothing matters‖; ―Would rather be dead than live this way‖; ―What's the use‖; ―Regret having lived so long‖; ―Let me die.‖ E1b. Persistent anger with self or others — For example, easily annoyed, anger at care received. E1c. Expressions, including nonverbal, of what appear to be unrealistic fears — For example, fear of being abandoned, being left alone, or being with others; intense fear of specific objects or situations. E1d. Repetitive health complaints — For example, persistently seeks medical attention, incessant concern with body functions. E1e. Repetitive anxious complaints/concerns (non-health-related) — For example, persistently seeks attention/reassurance regarding schedules, meals, laundry, clothing, and relationships. E1f. Sad, pained, or worried facial expressions — For example, furrowed brows, constant frowning. E1g. Crying, tearfulness — Distress may also be expressed through such nonverbal indications. E1h. Recurrent statements that something terrible is about to happen — For example, believes he or she is about to die, have a heart attack E1i. Withdrawal from activities of interest — Including long-standing activities, being with family/friends. E1j. Reduced social interactions E1k. Expressions, including nonverbal, of a lack of pleasure in life (anhedonia) — For example, saying ―I don't enjoy anything anymore.‖ Coding; Based on your interaction with and observation of the person, score each indicator based on the person's behavior over the last 3 days using one of the following codes. Remember, score each item based on what you see or what is reported to you, regardless of what you believe the cause to be. 0. Not present 1. Present but not exhibited in last 3 days — Use this code if you know the condition is present and active, even though it was not observed over the last 3 days. 2. Exhibited on 1-2 of last 3 days 3. Exhibited daily in last 3 days

G3. Locomotion/Walking

To record the primary mode of locomotion and type of appliances, aids, or assistive devices the person used over the last 3 days. ( Cane, scooter, walker, wheelchair) Code for the primary mode of locomotion used by the person indoors within the last 3 days. For persons who walk by pushing a wheelchair in front of them for support, or by using a walker-type device such as a Merry Walker, use code ―1‖ (―Walking, uses assistive device‖). 0. Walking, no assistive device 1. Walking, uses assistive device — For example, a cane, walker, crutch, or pushing wheelchair. 2. Wheelchair, scooter 3. Bedbound l

A13. Living Arrangement

To record whom the person lives with and the duration of this arrangement. These items will help the home care staff determine the need for more, fewer, or different services. Process Ask the person or family member. Record the code that reflects whom the person is living with presently. Note that this excludes any temporary arrangements in living made while home care services are being set up. 1. Alone — Includes person who lives only with a pet, lives on the streets, or is homeless. 2. With spouse/partner only — Includes spouse/partner, girlfriend or bofriend, common-law marriage, or long-term same-sex relationship. 3. With spouse/partner and other(s) — Lives with spouse or partner and any other individual(s), whether family or unrelated. 4. With child (not spouse/partner) — Lives with child(ren) only, or with child(ren) and other individual(s), but not with spouse or partner. 5. With parent(s) or guardian(s) — Lives with parent(s) or guardian(s) only, or with parent(s) or guardian(s) and other individual(s), but not with spouse or partner or child(ren). 6. With sibling(s) — Lives with sibling(s) only, or with sibling(s) and other individual(s), but not with spouse or partner, child(ren), or parent(s) or guardian(s). 7. With other relative 8. With nonrelative A13b. As compared to 90 DAYS AGO (or since last assessment), person now lives with someone new. A13c. Person or relative feels the person would be better off living elsewhere ―Do you believe the person would be better off living elsewhere? Code for the most appropriate response. 0. No 1. Yes, other community residence 2. Yes, institution

J3t. Hygiene —

Unusually poor hygiene, unkempt, disheveled

Assessment Reference Date

all information gathered about the person pertains to the 3-day period prior to and including the Assessment Reference Date for items pertaining to the person's status or performance.

H3. Bowel Continence

he term ―bowel continence‖ refers to control of the person's bowel movements Remember to consider continence patterns over the last 3 days, 24 hours a day. Coding 0. Continent — Complete control; the person does not use any type of ostomy device. 1. Control with ostomy — Control with ostomy device over last 3 days. 2. Infrequently incontinent — Not incontinent over last 3 days, but does have incontinent episodes. 3. Occasionally incontinent — Incontinent less than daily. 4. Frequently incontinent — Incontinent daily, but person has some control. 5. Incontinent — No control present. 8. Did not occur — No bowel movement in the last 3 days

Section Q Environmental Assessment

o determine if the home environment is hazardous or uninhabitable Disrepair of the home extremely dirty condition Inadequate heating or cooling Lack of personal safety limited access to home or rooms Availability of emergency assistance accessebility to grocery without assistance availabilibity of home delivery of groceries Code 0. No 1. yes Finances odetermine if limited funds prevented the person from receiving required medical and environmental support Limited Funds

G5. Physical Function Improvement Potential

that the person has the capacity for greater independence and involvement in his or her care G5a records the person's own opinion; G5b records the opinion of a care professional who knows Coding 0. No 1. Yes

Return assessment —

— An assessment conducted when the person returns from the hospital or re-enters the home care system after a planned absence.

Performance

— Measures what the person actually did within each IADL category in the last 3 days. Do not base your coding on what the person might be capable of doing 0. Independent — No help, setup, or supervision needed. 1. Setup help only 2. Supervision — Oversight/cuing required. 3. Limited assistance — Help required on some occasions. 4. Extensive assistance — Help required throughout task, but performs 50% or more of task on own. 5. Maximal assistance — Help required throughout task, but performs less than 50% of task on own. 6. Total dependence — Full performance of activity during entire period by others. 8. Activity did not occur — During entire period. NOTE: You may use this code to score the Performance category, but do not use it to score Capacity category

Discharge assessment, covers last 3 days of service

— Use this code whenever a permanent program discharge is anticipated and a full interRAI HC Assessment is completed. This is a means of ―closing‖ the clinical record at the point of discharge. Your agency or home care program will determine the type of discharge assessment to be completed (discharge assessment or discharge tracking only).