Assessing Your Needs for Long-Term Care

Many people prefer the idea of staying in their homes as they age. However, care needs can change over time. Some of those needs can be met while remaining in the home. Evaluating circumstances periodically can help to assure an individual’s safety and comfort along the way.

To determine the appropriate level of care that you or a loved one may require, a full assessment of what current daily needs are as they are related to certain activities should be addressed. Asking a professional such as your doctor, nurse, geriatric care manager, or hospital discharge planner to assist you in filling out this assessment could provide a more complete view of your care requirements.

Fill out the form to indicate if you currently require help for the following activities and how often you need help.

Do you need help with this activity?

No

Yes

If yes, is it sometimes or always?
How many times per day/per week?

Bowel/bladder control

 

 

 

Eating

 

 

 

Toileting

 

 

 

Dressing

 

 

 

Bathing

 

 

 

Transferring

 

 

 

Walking - indoors

 

 

 

Walking - outdoors

 

 

 

Go upstairs/downstairs

 

 

 

Driving

 

 

 

Cooking

 

 

 

Housekeeping

 

 

 

Yard Work

 

 

 

Laundry

 

 

 

Shopping

 

 

 

Using the phone

 

 

 

Managing finances

 

 

 

Taking medications correctly

 

 

 

 

Assessing Your Needs for Long-Term Care (cont.)

Are you currently receiving care or supervision each day?        YES    NO

Explain:

 

FOR WHAT:

HOW OFTEN:

WHO IS PROVIDING THE CARE:

 

 

 

 

 

 

 

 

 

List any assistive devices, i.e., cane, walker, grab bars, bed rails, modifications to communication or listening devices, oxygen, shower seat, medication reminder, Personal Emergency Response System, etc.
__________________________________________________
__________________________________________________
__________________________________________________

 

What other restrictions do you have:
__________________________________________________
__________________________________________________
__________________________________________________

 

Do you prefer having someone with you during the day?          
YES     NO

Do you feel isolated or lonely?          YES    NO

Are you able to call someone for help if you would need it?       YES    NO

Are you comfortable with someone coming into your home?      YES     NO

 

Describe any other assistance needs or concerns you have that have not been asked already:
__________________________________________________
__________________________________________________
__________________________________________________

 

Condition of Your Home - Is your home ready to take care of you?

If it is determined that the level of care you require allows for you to remain at home, the next step is establishing if your home is conducive to your care needs. Physical and Occupational therapists are good resources for evaluating your home environment in relation to your need for care.

 

Considerations for comfort in your home:

 

Are there steps in your home that would be a problem for you?

Outside the house:            YES     NO     

Change to be made: ________    Approximate cost: ________

Leading into the house:       YES    NO     

Change to be made: ________    Approximate cost: ________

From one floor to another:  YES     NO

Change to be made: ________    Approximate cost: ________

Between rooms:               YES     NO  

Change to be made: ________    Approximate cost: ________

 

Are hallways and doorways wide enough for a wheelchair or walker to get through?
YES     NO

Change to be made: ________    Approximate cost: ________

 

Are counters, drawers, cabinets, stove, oven, and refrigerator at appropriate levels?   
YES     NO    

Change to be made: ________    Approximate cost: ________

 

Are kitchens and bathrooms big enough to navigate with any assistive devices?
YES     NO

Change to be made: ________    Approximate cost: ________

 

Do you need assistive devices installed? Grab bars, stair glide, ramps, etc.?
YES     NO

Change to be made: ________    Approximate cost: ________