Download VSHP CHOICES Telephone Screening Tool V

MD TELEPHONE SCREEN: ITEM BY ITEM GUIDE
This document provides guidance for individuals who will be involved in the pilot test of the
Maryland telephone screen. All items used here, with the exception of those with an asterisk
at the end of the item, are abbreviated versions of the same items from the interRAI Home
Care assessment instrument. While they seek the same information, they have been rewritten
for use as a telephone screen and are generally less detailed. If you would like more
information about an item, consult the interRAI user manual.
Ask items in a conversational manner to help put the person at ease. (In everyday use, after
the screener becomes familiar with the items, they can be asked when the appropriate subject
comes up in a conversation.) There is no need to ask an item if the person clearly provides
the information in the course of conversation.
Keep re-phrasing of items to a minimum to insure consistency. Be patient. If the person
doesn’t respond, acknowledge this by asking if the person would like you to re-state the item.
Also ask whether the person can hear you adequately.
In cases where the person is unable/unwilling to take part in the screen, speak to the main
unpaid helper if at all possible.
Fill out the feedback items for each screen; these are important to the research effort. Be sure
to note the time you begin each screen so you have an accurate estimate of the duration of the
screening.
Thanks to the South Dakota Department of Social Services for sharing a version of this screen
guide.
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To be determined before performing screen:
1. Does the caller have any history of mental illness?
Note: Mental illness includes any concerns about emotional wellness that interfere with
quality of life or daily functioning. This includes depression, anxiety, psychosis, loss of
interest in daily activities, etc.
0. No
1. Yes
2. Does the caller have any history of abusing alcohol or drugs?
Note: Substance abuse includes any use that interferes with quality of life or daily
functioning and reports that others have advised them to seek help for addictions.
0. No
1. Yes
3. Does the caller have any history of brain injury?
Note: Brain injury is indicated by a report of a blow to the head, being "knocked out," a
concussion, lost consciousness, or being in a coma following an injury (motor vehicle or
bicycle accident, fall, assault).
0. No
1. Yes
4. Does the caller have any history or diagnosis of developmental or intellectual
disability?
0. No
1. Yes
5. Has the caller ever served in the military?
0. No
1. Yes
Script:
I’d like to have a conversation with you to find out how you do everyday tasks and to
learn more about your health. This will take about fifteen minutes. It’s important that
you tell me how things really are going for you, as accurately as possible, so I can make
sure you get the kind of assistance that will best meet your needs.
First, I’d like to understand more about your ability to do some everyday tasks. I’m
interested in your ability to do these tasks, not whether you actually did them.
1. In the last three days, were you able to go SHOPPING, including selecting items
to buy and paying for them? (Exclude transportation.)
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0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
Set-up help only: Making a list of needed items, provides the checkbook or needed cash to
the person and the person then independently shops.
Supervision-oversight, cueing: Being with the person to point out needed items, reminding
him/her how to write out the check and to write the amount in the checkbook
More assistance needed: Writing the check for the person, selecting the food items, etc.
2. In the last three days, were you able to PREPARE MEALS?
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
Set-up help only: Setting out meal ingredients or the food that the person will heat up on
his/her own
Supervision-oversight, cueing: Prompting the person during the meal preparation; assuring
the stove/oven/microwave is used in a safe manner and turned off after the meal is
cooked/heated; reminding the person to refrigerate perishable items
More assistance needed: Mixing the ingredients together, cooking the meal
Note: Receiving home delivered meals (through a nutrition site or from a family member or a
using a TV dinner) does not mean the person is unable to prepare his/her meals. How the
person heats up the meal is a consideration for such instances.
3. In the last three days, were you able to DRIVE yourself, get in or out of a car,
or use public TRANSPORTATION?
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
Set-up help only: Arranging for transit service or other transportation (and then the person is
able to independently access transit or other transportation)
Supervision-oversight, cueing: A helper remains nearby to make sure the person gets into
and out of the vehicle, guiding or guarding without physical assistance or with minimal or
intermittent physical contact
More assistance needed: Physical support getting into and out of the vehicle
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4. In the last three days, were you able to do WORK AROUND THE HOUSE, like
doing dishes, making the bed, doing laundry, or straightening up?
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
Set-up help only: Getting out cleaning supplies and the person independently completes the
task
Supervision-oversight, cueing: Writing a list of tasks to be completed, prompting the person
to complete the task and stay on task; verbal reminders with certain tasks
More assistance needed: Physical assistance to help person perform or complete tasks
5. In the last three days, were you able to manage use of the phone?
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
6. In the last three days, were you able to MANAGE your MEDICATIONS?
(Includes remembering when to take pills, opening the bottles, and taking the right
dosages.)
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
Set-up help only: Setting out/opening medication bottles or placing medication in a cup or pill
minder, writing a list of medications to take and when to take the medication
Supervision-oversight, cueing: Reminding the person to take the medication and assuring
the person takes the medication; use of an electronic pill dispenser (a helper sets the
medication time (s) and the person takes the medication when alarm reminds the person)
More assistance needed: Administer the medications, ensure medications are swallowed
7. In the last three days, were you able to MANAGE your FINANCES, like
paying bills, balancing your checkbook, or checking your credit card balance?
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
Set-up help only: Setting out bills to be paid; providing a calculator, checkbook, pen, etc.
Supervision-oversight, cueing: Reminding the person which bills should be paid, cueing
about how the checks should be written
More assistance needed: Writing the checks, arranging for bill pay, balancing the checkbook
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SCRIPT: Now I’d like you to tell me about what you have done recently. I want to know
what you have actually done by yourself, or others have done for you, NOT whether you
are able to do these activities.
8. In the last three days, how much have you engaged in any PHYSICAL ACTIVITY,
such as walking, cleaning the house, or exercising?
0. More than 2 hours
1. Not performed or performed 2 hours or less
Considerations: The accumulated time in the three days; the time does not have to occur all at
once on a given day.
9. In the last three days, has your condition required that meals be prepared
FULLY by others?
0. No
1. Yes
2. Activity did not occur
.
10. In the last three days, what ASSISTIVE DEVICES have you used to MOVE
AROUND INDOORS?
0. No assistive device
1. Cane or walker
2. Wheelchair or scooter
3. Activity did not occur
Independent-no help, set-up, or supervision: The person performed the activity or task
alone, without help, set-up or supervision.
Set-up help only: The person is provided with materials, devices, or preparation to perform
an activity independently. Includes giving or holding out an item that the person takes and
the helper then leaves the person alone to complete the activity.
Supervision-oversight, cueing: If the helper remains nearby to watch over the person; if
the helper provides prompts to the person, i.e., “take a bite”, “slow down”, “don’t forget to
rinse your hair,” etc.
More assistance needed: If the helper provides more assistance than set-up help or
supervision-oversight, cueing.
Activity did not occur: The activity was not performed.
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11. In the last three days, what kind of help did you get to MOVE AROUND
INDOORS? (Note: if person used a wheelchair, score for self-sufficiency once in
wheelchair.)
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
4. Activity did not occur
Set-up help only: Handing the person a walker or cane; positioning walker or wheelchair
within easy access for the person to use the assistive device
Supervision-oversight, cueing: Remaining nearby to watch over the person or guide
movements
More assistance needed: Providing support by holding person under armpit or allowing
person to lean on arm
12. In the last three days, what kind of help did you get to DRESS YOURSELF?
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance used
4. Activity did not occur
Set-up help only: Picking out the clothes; placing the person’s clothes out for them to put on;
holding out the shirt or clothing article for the person to take – and then leaving the person
alone to dress themselves
Supervision-oversight, cueing: Remaining nearby to watch over the person; reminding the
person to put on certain articles of clothing or to button the clothing
More assistance needed: Physically helping the person put on the clothing and helping with
the buttoning or snapping of clothing; completing pulling up the person’s pants or repositioning
clothing articles
13. In the last three days, did you use any help to use the toilet?*
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance used
4. Activity did not occur
14. In the last three days, did you use any help to MOVE AROUND IN BED?
(Includes moving to and from a lying position to a sitting position, turning from side to side,
and repositioning body while in bed)
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance used
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4. Activity did not occur
Independent: Includes use of a trapeze that is suspended from a frame which may be
freestanding or attached to the bed to move around in bed.
Set-up help only: Turning down the bed covers
Supervision-oversight, cueing: Guiding the person to a lying position with minimal physical
contact or intermittent physical guarding
More assistance needed: Holding the full weight of the arm and/or back to move to and from
the lying position; fully positioning the body in bed; physically turning the person during
resting or sleeping time.
15. In the last three days, did you use any help to BATHE, SHOWER, or
TAKE A SPONGE BATH?
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
4. Activity did not occur
Set-up help only: Providing the person with bathing article (s) (soap, washcloth, towels, etc.)
so the person performs independently. This includes giving or holding out an item that the
person takes from another person and the person leaves the person alone to complete the
activity
Supervision-oversight, cueing: If someone remains nearby to watch over the person,
cueing for the activity, and/or guiding or guarding the person with minimal physical contact
More assistance needed: Assisting the person to raise an arm; weight bearing assistance in
or out of tub.
16. In the last three days did you use any help to TRANSFER from one position to
another? (Includes moving from bed to chair or wheelchair, or rising out of a chair
to a standing position.)
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
4. Activity did not occur
Independent: Includes when a person uses a lift chair to get to a standing position.
Set-up help only: Handing the person a walker, cane, etc; positioning an assistive device or
furniture within the person’s reach.
Supervision-oversight, cueing: Remaining nearby to guide or guard the person with minimal
or intermittent physical assistance
More assistance needed: Taking the person’s full weight by holding him/her under the armpit
or allowing the person to lean on another person’s arm
Note: This item does not include transfer to or from the toilet.
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17. In the last three days did you use any help to EAT?
(Includes taking in food by any method, including tube feeding.)
0. Independent—no help, set-up, or supervision
1. Set-up help only
2. Supervision—oversight, cueing
3. More assistance needed
4. Activity did not occur
Set-up help only: Cutting up food into bite size pieces; opening containers
Supervision-oversight, cueing: Prompting or reminding the person to slow down, to chew
food, to take smaller bites of food, to swallow food
More assistance needed: Physically helping the person to eat, e.g., spoon feeding the
person his/her food
SCRIPT: Next, I’d like to learn more about your living arrangements.
18. Are there any hazards that make it DIFFICULT for you TO ENTER, MOVE AROUND
IN, or LEAVE YOUR HOME?
0. No
1. Yes
Considerations:
 Difficulty entering or leaving the home
 Difficulty maneuvering within rooms
 Includes physical problems that limit access: weak or broken stairs; loose or missing
stair railings entering the home or within the home; only entrance/exit has stairs; no
ramp/lift
 Carpeting prevents person using walker or cane from moving around in home
 High thresholds or narrow doorways prevent movement
19. In the last 90 days, have you MOVED IN WITH OTHERS, or HAVE OTHERS MOVED IN
with you?
0. No
1. Yes
20. In the last three days, have you been LEFT ALONE in the morning or afternoon?
0. No—person is never or hardly ever left alone
1. Yes—person is left alone, even if only for about one hour
Considerations:
 Person is literally alone, without anyone else in the home
 If in congregate housing or other situation where others are present, time person
spends by himself/herself in his/her own room
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21. Do you, or does your main helper, if any, believe that you would be BETTER OFF
ELSEWHERE?
0. No
1. Yes
Considerations:
 Would the person be happier living somewhere else?
 Would the person be less isolated living elsewhere?
 Would the person’s needs be met better?
 Would the person feel safer?
SCRIPT: Now I’d like to ask you a few questions about your health.
22. In the last three days, have you had a flare up of a RECURRENT or CHRONIC
HEALTH PROBLEM?
0. No
1. Yes
23. In the last three days, have you had any TROUBLING SKIN CONDITIONS,
such as burns, tears, open lesions, bruises, or rashes?
0. No
1. Yes
24. In the last three days, have you received any of the following care:
a. CARE OF A WOUND OR PRESSURE ULCER, or moving/turning to
prevent skin breakdown?
0. No
1. Yes
A pressure ulcer is any lesion caused by unrelieved pressure. Pressure ulcers usually occur
over bony prominences (heel, elbow, knee); an area of skin that appears continually reddened;
an abrasion, blister, or skin crater.
b. HOME CARE AIDE
0. No
1. Yes
Any paid staff who provides “hands-on” ADL support and monitoring of health status.
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c. PHYSICAL THERAPY
0. No
1. Yes
Physical therapy services are provided or directly supervised by a qualified physical therapist.
A qualified physical therapy assistant may provide therapy.
d. SOCIAL WORKER
0. No
1. Yes
e. Monitoring by a NURSE?
0. No
1. Yes
Monitoring by a licensed or registered nurse who provides assessment of person’s health
status.
f. Treatment with IV (intravenous) medication?
0. No
1. Yes
25. In the last three days, have you had any of the following problems?
a. been EASILY DISTRACTED, HAD TROUBLE PAYING ATTENTION,
or BECOME SIDETRACKED?
0. Behavior not present
1. Behavior present, consistent with usual functioning
2. Behavior present, new onset or worsening
b. threatened, cursed or screamed at others?
0. Behavior not present
1. Behavior present
Considerations:
 The person becomes angry easily
 Loses temper
c. wandered several times a day?*
0. Behavior not present
1. Behavior present
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d. had hallucinations or delusions?*
0. Behavior not present
1. Behavior present
e. displayed any self-injurious behavior?*
0. Behavior not present
1. Behavior present
Code items #26, #27, #28 based on your conversation with the consumer; DO NOT ask
the consumer directly. Ask as questions if interviewing a third party.
26. In the last three days, how well did the person made themselves understood?
0. Person is understood even if s/he has difficulty finding words or finishing thoughts
1. Person is limited to making concrete requests or is rarely or never understood
27. In the last three days, how well did the person MAKE DECISIONS about
organizing the day, for example, when to get up or have meals, what clothes to
wear, what to do?
0. Person made decisions independently
1. Person made decisions with difficulty or decisions were poor
2. Person rarely or never made decisions
Considerations for scoring difficulty:
 Person always looks to another before making a decision
 Person always ask others for advice
28. In the last three days, did the person have DISORGANIZED SPEECH, RAMBLE
FROM SUBJECT TO SUBJECT, or LOSE THEIR TRAIN OF THOUGHT?
0. Behavior not present
1. Behavior present, consistent with usual functioning
2. Behavior present, new onset or worsening
Considerations:
 Looking for recent changes in usual function
Financial Questions
Eligibility for Medicaid depends on an individual’s income and assets. Individuals are
encouraged to apply so that financial eligibility may be determined. Certain waiver
programs may accept individuals with a different level of income than other traditional
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Medicaid programs. Trained Eligibility Case Managers make the final determination of
eligibility. For individuals who do not meet the Medicaid financial eligibility requirements,
there is the option to pay privately.
29. Are you currently receiving any of the following?
a. Supplemental Security Income
0. No
1. Yes
b. Medicaid
0. No
1. Yes
30. Marital Status
0. Single
1. Married
30a. If single, do you have assets at, or below, $2,500? (Not including house and car)
0. No
1. Yes
30b. If married, do you have assets at, or below, $3,000? (Not including house and
car)
0. No
1. Yes
31. Is your gross monthly income at or less than $2,094? Income is gross and
includes but not limited to Social Security, Veteran’s Benefits, Pensions, income
from rent and investments, Interest, Alimony
0. No
1. Yes
31a. If single, is your monthly income less than $350?
0. No
1. Yes
31b. If married, is your monthly income less than $392?
0. No
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