Module 4: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

NOTE: In 2009, Department staff recorded two training webcasts that provided overviews of changes made to this module. To view the webcasts go to: View ADLs webcast | View IADLs webcast (If you have not seen a webcast before, check your computer to see if it meets the minimum requirements.)

Contents

• 4.1 Sections in this Module of the LTC FS: ADLs and IADLs
• 4.2 Overview of ADLs/IADLs
• 4.3 Choosing Level of Help Ratings for ADLs/IADLs 
• 4.4 Communal Living Situations
• 4.5 Adaptive Equipment 
• 4.6 Coding for Who Will Help in Next 8 Weeks
• 4.7 Bathing
• 4.8 Dressing
• 4.9 Eating
• 4.10 Mobility in Home
• 4.11 Toileting
• 4.12 Transferring
• 4.13 Meal Preparation
• 4.14 Medication Administration and Medication Management
• 4.15 Money Management
• 4.16 Laundry and/or Chores
• 4.17 Telephone
• 4.18 Transportation
• 4.19 Overnight Care or Overnight Supervision
• 4.20 Employment 

Objectives

By the end of this module you should be able to:

• Define the six activities that make up the Activities of Daily Living section and the seven activities that make up the Instrumental Activities of Daily Living section of the LTC FS.
• Apply the rating system used with each ADL/IADL accurately and reliably. This means that other screeners would select the same answer as you did.
• Properly Code "who will help in the next 8 weeks" for each ADL/IADL.
• Identify the adaptive equipment items that are included in the ADL section of the LTC FS.
• For someone preparing for discharge from a skilled healthcare facility, complete the ADLs/IADLs sections reflecting how the person would function at home.
• Utilize strategies to counter an individual's tendency to underrate/overrate their need for assistance with ADLs/IADLs.

4.1 Sections in this Module of the LTC FS: ADLs and IADLs

Activities of Daily Living (ADL)

1. Bathing
2. Dressing
3. Eating
4. Mobility in Home
5. Toileting
6. Transferring

Instrumental Activities of Daily Living (IADL)

1. Meal Preparation
2. Medication Management and Administration
3. Money Management
4. Laundry and/or Chores
5. Telephone
6. Transportation
7. Employment

4.2 Overview of the ADLs/IADLs Module

The Long Term Care Functional Screen (LTC FS) collects data on an individual's ability to accomplish Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Many times individuals have adapted to a deficit, and may appear fairly functional, but still have the underlying deficit.

Each ADL and IADL is defined in the LTC FS Instructions. Follow those definitions closely.

While one rating system has been developed for all of the ADLs, the IADLs require separate ratings because their respective descriptions are so different.

ADL RATING SYSTEM:

• 0: Person is independent in completing the activity safely.
• 1: Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task.
• 2: Help is needed to complete the task safely and helper DOES need to be present throughout the task.

Note: Help can be supervision, cueing, and/or hands-on assistance (partial or complete).

IADL RATING SYSTEM: (Vary by IADL)

In all cases, the rating has been simplified to meet the following criteria:

• Simplicity for maximum uniformity (inter-rater reliability): This is imperative for accurate and equitable determination of eligibility and entitlement.
• Inclusive: A screener is able to select one "most accurate" answer for every individual of any of the LTC FS target populations.
• Make sense for eligibility: Some things should not "count" toward eligibility for a LTC program.
• Relate to long term care costs.

Tips for completing the ADL/IADL Module:

• Identify the need and select the level of help needed from another person.
  
  
• Be careful not to overlook deficits because of adaptations made. Consider a person's use of self-made assistive devices used in lieu of more standard medical equipment (e.g., use of a lawn chair as a shower chair).
  
  
• It is not uncommon for individuals to under-rate their need for help or overstate their independence. Remember to use the following five steps when reviewing the level of help needed:
  • Select the level of assistance needed based on need and not solely on a diagnosis.
  • Select the level of assistance needed and not solely on the report of the individual.
  • Seek more details and consider asking for a demonstration on how a task is completed.
  • Seek collateral informants, other people you could ask for additional information.
  • Use your professional judgment and assessment skills to select the best answer. Follow the definitions and instructions for the screen.
    
    
• For a person living in a residential facility, assess the person's actual need for assistance and do not select the level of help needed based on the services or equipment available as part of the residential facility package.
  
  
• When an individual's conditions and abilities fluctuate over time, reference Module 1.12 Strategies to Minimize Screening Limitations, Abilities Fluctuate, for assistance on how to complete the LTC FS.
  
  Example: Bert tells you he doesn't need any help with bathing. He lives alone. He is unkempt and has body odor. He walks very unsteadily with a cane and is bent over. It is quite clear to you that he is not able to safely get in and out of his bathtub and that he in fact has not bathed for many weeks.
  
  
  • Step 1: Seek more details:
    • You ask him if you can see his bathroom, where you notice he has a claw-foot bathtub with sides about 2 feet high off the floor (with no grab bars, bench, or non-slip mats). You observe his ambulation and ask him to lift his foot high for you. He lifts it about four inches. You ask him for details on how he gets in and out of the bathtub.
      
      
  • Step 2: Seek collateral informants:
    • Bert's daughter referred him to the Resource Center and is present during the screen interview. With Bert's approval, you speak to her privately on the way out to get her perspective on her dad's functioning. She says he is lying now because he's afraid, but he's admitted to her that he is unable to get into the bathtub.
      
      
  • Step 3: Use your professional judgment to select the best answer:
    • You can see from Bert's general body movement that he would need help with all aspects of bathing and would require his helper to be present throughout the entire task. For bathing, select Box 2, "Helper needs to be present throughout the task".

If you have identified a level of help needed in ADLs or IADLs, be sure to indicate a diagnosis that correlates to the deficit. In the event no diagnosis is currently available to verify the care need, clearly state in the notes section why the deficit is present. This is also true for the other modules where deficits are noted.

The need for assistance with personal hygiene such as grooming and mouth care are not captured on the LTC FS. This information, as well as hygienic conditions of the home should be captured on a comprehensive assessment.

Employment is not traditionally considered an IADL, but is on the LTC FS. On the LTC FS, chores and laundry are included in the IADL section but do not "count" as IADL deficits in the current eligibility logic. Also included in this section is a question regarding Overnight Supervision, however this is not an IADL.

4.3 Choosing Level of Help Ratings for ADLs/IADLs

The ADLs/IADLs Module of the LTC FS is intended to determine whether a cognitive or physical impairment limits a person's ability to perform an activity or causes significant difficulty in performing an activity alone, with or without adaptive aids. A determination that an individual is limited in his/her capacity to perform an ADL or IADL task should always equate with a cognitive or physical impairment.

Always select the answer that most closely describes the person's need for help from another person--whether they are actually getting that help or not. Always select ONLY ONE rating of help needed with each ADL and IADL.

For each ADL and IADL, indicate the amount of help the person currently needs from another person--no matter who is providing the help. The only exception to this is when a person is about to change residences, estimate what assistance they'll need in their new residence.

If a person can complete a task independently, but it takes them a very long time, you need to consider if the person needs any help with that task to complete it safely. If they are in fact completing tasks safely, it does not matter if it takes two or three times longer than for most people. However, if it takes a significant amount of time for the person to complete a task independently and that results in a significant, negative health outcome for the person doing the task so slowly, to the point that another person should be present to help with some or all of the task, than it would be justified to indicate the person has a need of help completing the task.

REMINDER: A screener should document an individual's NEEDS, not just what services/assistance they are currently receiving. So, if a person has an identified need, but for some reason is not receiving assistance (including refusing the service, etc.), the screener should still capture the need for the assistance in this section.

REMINDER: If a person has never performed an activity or a task, do not assume the person is physically or cognitively capable or incapable of doing so. A lack of experience is not the same as the inability to perform a task due to a physical or cognitive impairment. And, although a person is currently receiving assistance with a task they may be able to perform the activity independently or with limited assistance if given the opportunity and training.

4.4 Communal Living Situations

A screener may encounter a person living in a communal living situation or congregate living arrangement, like a dormitory, convent, monastery, etc. This person may lack experience performing certain tasks. Socioeconomic barriers, religious beliefs, or cultural norms may be factors that result in this person having fewer opportunities to perform select IADLs (e.g., making phone calls, managing a checkbook, driving, or food preparation). In a communal living situation, activities are often centralized and tasks assigned to certain individuals for the convenience of the community or setting.

When a person resides in a communal living situation, do not presume ADL and IADL tasks cannot be performed by the person unless a physical or cognitive limitation is evident. Assume the person can be independent when the opportunity and training are provided to learn new tasks. When a person is receiving assistance with an ADL/IADL task or has no experience performing the task, the screener must:

1. Ascertain whether there are communal living situation, socioeconomic barriers, religious beliefs, or cultural norms factors that result in the individual receiving assistance or lacking experience with a task.
2. If such factors are evident, determine whether there is a physical or cognitive impairment limiting the person's capacity to perform the task.

Examples:

• A college student living in a dormitory who has relied on his parents to manage his financial matters. Do not assume this student is unable to manage money and pay bills unless he has a physical or cognitive impairment limiting his ability to do so.
• A nun has taken a vow of poverty and has spent her adult life in a convent. Financial resources have always been pooled and bills paid centrally. Money available to her has been limited to a small stipend. Do not assume this nun is unable to manage money and pay bills unless she has a physical or cognitive impairment limiting her ability to do so.
• A large farm cooperative is managed by a religious order of monks living at the farm in a monastery. The monks have experience with farming tasks but not driving, shopping, and food preparation. When determining a monk's ability to perform these IADL tasks, assess for any functional or cognitive limitations that may diminish his capacity to perform these IADL tasks, not the inexperience or lack of training opportunities.

4.5 Adaptive Equipment

Four of the ADLs (Bathing, Mobility, Toileting, and Transferring) and two of the IADLs (Meal Preparation and Laundry and/or Chores) have some adaptive equipment listed. Select only equipment the person currently needs, has, and is actually using. 

Sometimes a person will improvise to meet a need for equipment. For example, instead of a tub bench they may use a sturdy object to sit on during bathing. In this instance, you would not select 'Uses tub bench' in the bathing equipment box. Do not capture a person's use of improvised or home-made items as a substitute for the equipment on the list. A screener should only select the types of equipment listed on the LTC FS the person needs, has, and uses.

Do NOT select a type of equipment that is a facsimile of what is on the list. 

If a person uses an improvised or home-made item and without it, they do not need any assistance from another person to complete the task, the screener should select 0: (Independent). Do NOT check the use of any equipment. 

If a person uses an improvised or home-made item and without it, they would need assistance from another person to complete the task, the screener should select 1: (Help is needed-helper need not be present throughout the task). Do NOT check the use of any equipment (for the improvised or home-made item).

4.6 Coding for Who Will Help in the Next 8 Weeks

For each ADL and most of the IADLs there are codings to indicate who will help in the next 8 weeks. Check all that apply.

• U: Current UNPAID caregiver will continue.
• PP: Current PRIVATELY PAID caregiver will continue.
• PF: Current PUBLICLY FUNDED paid caregiver will continue.
• N: Need to find new or additional caregiver(s).

Although the level of unpaid or privately paid assistance a person receives will NOT affect a person's level of payment in the new system, this information will be used for two purposes:

1. To inform the LTC program that the person may need services immediately or soon, so the team can anticipate finding additional assistance for the person.
2. To inform the Department of reasons for low costs for persons with high needs, so that adequate average payments can be established.

If the level of assistance needed for a particular ADL/IADL task is selected as 0: (Independent) or NA: (Has no medications), the boxes for "Who Will Help in the Next 8 Weeks?" should be left blank.

If it is determined the person needs assistance with a task, the "Who Will Help in the Next 8 Weeks?" category is mandatory to complete. In other words, if a level of assistance indicated for an ADL or IADL task is "1" or greater the screener must select at least one of the "Who Will Help" boxes.

PP: (Current Privately Paid caregiver will continue) means non-public funding, including the person's own money, or that of family, friend, etc., private insurance (including LTC insurance benefits), or a trust fund.

PF: (Currently Publicly Funded paid caregiver will continue) means funded with public program assistance including but not limited to services funded by Medicare, Medicaid, waiver programs, Veterans Affairs, and any other federal, state, or county funding sources.

Nursing Home or Hospital Resident

If a person resides in a nursing home or hospital and discharge is not expected in the next 8 weeks, indicate how the nursing home is being paid (Privately Paid or Publicly Funded). If a person is in a nursing home and they are expected to be discharged within the next 8 weeks, try to be as accurate as possible with the "Who Will Help" boxes. Record the help the person will need once at home. Many elders are discharged to their own homes with a mixture of public, private, and unpaid care giving services.

DEFINITIONS AND DISCUSSION OF ADLs

4.7 Bathing

Definition: The ability to safely shower, bathe, or take a sponge bath for the purpose of maintaining adequate hygiene. The activity of bathing consists of the following components:

• Ability to get in and out of the bathtub/shower
• Turning on and off the faucets
• Regulating the water temperature
• Washing and drying self fully
• Shampooing hair

Equipment that can be counted under bathing includes:

• Shower chair
• Tub bench
• Grab bars
• Mechanical lift

Check this for a person who:

• Requires supervision, cueing, and/or hands-on assistance (partial or complete) with any of the above mentioned components of bathing.
  
  
• Requires regular cueing or would not bathe, due to a cognitive impairment.
  
  
• Gives themselves a sponge bath because they are unable to get in and out of tub/shower.
  
  
• Is able to bathe themselves but it takes additional time to do so and results in a significant, negative health outcome. During the task of Bathing, a significant, negative health outcome is indicated when a person experiences any of the following results: out-of-breath, dizzy, chest pains, exhausted, incontinence, or increased pain, to the point that another person should be present to help with some or all of the task.
  
  
• Requires assistance with the aspects of bathing but can be left alone to soak in the tub.

Do NOT check this for a person who:

• Has no cognitive impairment and chooses not to bathe.
  
  
• Bathes independently with the use of a hand held shower aid.
  
  
• Requires assistance with grooming tasks (shaving, brushing hair, mouth care, nail care, etc.).
  
  
• Prefers to have a sponge bath and can do so independently.
  
  
• Is able to bathe independently but doesn't bathe unless a family member/staff is present somewhere in the home, "just in case."
  
  
• Is able to bathe independently but it takes additional time to do so WITHOUT significant hardship or negative outcomes.

4.8 Dressing

Definition: The ability to dress and undress as necessary, with or without the aid of adaptive devices. The activity of dressing consists of the following components:

• Dressing the top half of body (includes putting on undergarments).
• Dressing the bottom half of body (includes putting on undergarments).
• Getting shoes and socks on and off.
• The ability to put on or remove prostheses, braces, and/or anti-embolism hose (e.g., TED stockings).
• The ability to work fasteners (e.g., snaps, buttons, and zippers) except at the back of a dress or blouse.
• Choosing the appropriate clothing for the weather.

Check this for a person who:

• Requires supervision, cueing, and/or hands-on assistance (partial or complete) with any of the above mentioned components of dressing.
  
  
• Needs clothes laid out for them, but can put them on.
  
  
• Is able to dress themselves but it takes additional time to do so and results in a significant, negative health outcome. During the task of Dressing, a significant, negative health outcome is indicated when a person experiences any of the following results: out-of-breath, dizzy, chest pains, exhausted, incontinence, or increased pain, to the point that another person should be present to help with some or all of the task.

Do NOT check this for a person who:

• Only requires assistance with a zipper or button(s) at the back of a dress or blouse.
  
  
• Does not have a cognitive impairment, but chooses not to wear appropriate clothing.
  
  
• Can dress, but refuses to change their clothes, even when clothes are stained or carry an odor.
  
  
• May mismatch clothes.
  
  
• Is able to dress themselves but it takes additional time to do so WITHOUT significant hardship or negative outcomes.

4.9 Eating

Definition: The act of getting food or drink from a plate or cup to the mouth (chewing if necessary and swallowing) using routine or adaptive utensils. This also includes the ability to cut the food. Assess the individual's actual need for assistance. Do not select the level of assistance needed based solely on a diagnosis.

(Note: If the person is fed via tube feedings or intravenously, check Box 0 if they can independently complete that task, or Box 1 or 2 if they require assistance from another person.)

Adaptive utensils can consist of: weighted and/or built up eating utensils, scooper plates/bowls, food bumpers, special cups, etc.

Check this for a person who:

• Requires monitoring, supervision, hands-on assistance, or cueing to even complete the process of eating.
  
  
• Requires supervision due to a risk of choking.
  
  
• Requires assistance from another person to cut food.
  
  
• Has Prader-Willi Syndrome.
  
  
• Requires assistance to put on or remove a splint with which they can then hold a utensil and independently feed themselves.

Do NOT check this for a person who:

• Has no history or risk of choking but is monitored "just in case."
  
  
• Needs portion control for weight reduction.
  
  
• Is on a special diet (diabetic, low-cal, low-sugar, low fat, etc.).
  
  
• Must have food pureed, minced, or follows a mechanical soft diet (these needs are captured in Module 4.13 Meal Preparation tasks).
  
  
• Needs assistance placing food on a plate or with carrying a plate/cup to the table (these needs are captured in Module 4.13 Meal Preparation).
  
  
• Needs to have a plate "set up" with food due to his/her visual impairment.
  
  
• Is a messy eater.
  
  
• Takes other people's food.
  
  
• Needs the refrigerator, pantry, etc. to be locked to deter snacking or stealing (except for a person with Prader Willi Syndrome).
  
  
• Has pica or polydipsia (these needs are captured in Module 8 Behaviors/Mental Health as Self-Injurious Behaviors).
  
  
• Is able to feed themselves independently with adaptive utensils.

4.10 Mobility in Home

Definition: The ability to move between locations (including stairs) in the individual's living space. Living space is defined as kitchen, living room, bathroom, and sleeping area. A person's living space does not include the basement, attic, garage, yard, and places outside of the home. Excluded from the task of Mobility in Home is the need for assistance with a transfer to get up to a standing position to walk (this need is captured in Module 4.12 Transferring).

For an individual able to independently move about the home while using one of the types of equipment listed below, select 0 - Person is independent in completing the activity safely. Then check the corresponding box to indicate what equipment the individual uses.

The only equipment that can be counted under Mobility in Home includes:

• Walker
• Cane/quad cane*
• Crutches
• Wheelchair (used in the home)
• Scooter (used in the home)
• Artificial foot or leg(s)

Do not include the following types of equipment or medical supplies used by an individual as a type of equipment counted under Mobility in Home:

• Ace bandage
• Leg brace
• Foot brace
• Anti-embolism hose
• Neoprene Wrap
• Orthotic shoes
• Walker, cane, crutches, wheelchair, scooter, prostheses only used when ambulating outside of their home.

*A cane intended solely as a probe to identify obstacles or as an indicator of visual impairment does not count as an aid for Mobility in Home.

Check this for a person who:

• Uses the furniture or walls for balance.
  
  
• Requires standby** or hands-on assistance with mobility.
  
  
• Is able to walk (or wheel) themselves with or without equipment, but it takes them additional time to do so and results in a significant, negative health outcome. During the task of Mobility in Home, a significant, negative health outcome is indicated when a person experiences any of the following results: out-of-breath, dizzy, chest pain, exhausted, incontinence, or increased pain, to the point that another person should be present to help with some or all of the task.
  
  
• Can independently move about their home, but needs assistance to use steps in their living space (limited to the kitchen, bathroom, bedroom, and living room).

Do NOT check this for a person who:

• Is able to walk (or wheel) themselves when using adaptive equipment.
  
  
• Is able to walk (or wheel) themselves but needs direction on where to go due to a cognitive impairment.
  
  
• Requires assistance with mobility outside of the home.
  
  
• Is able to walk independently once assisted to a standing position (this need is captured in Module 4.12 Transferring).
  
  
• Is able to walk (or wheel) themselves but has had a joint replacement surgery.
  
  
• Is able to walk (or wheel) themselves, but has an uncontrolled seizure disorder.
  
  
• Is able to walk (or wheel) themselves but has a vision impairment.
  
  
• Is able to walk (or wheel) themselves but has a fear of falling.
  
  
• Is able to walk (or wheel) themselves but does so slowly and safely.
  
  
• Is able to walk (or wheel) themselves but has a shuffling gait and walks safely.
  
  
• Is able to walk (or wheel) themselves but it takes additional time to do so WITHOUT significant hardship or negative outcomes.
  
  
• Is able to walk (or wheel) themselves but needs assistance using steps or ramp outside of living space.
  
  
• Is able to walk (or wheel) themselves but does not get up and walk in the home unless a family member/staff is present somewhere in the home, "just in case."
  
  
• Is able to walk (or wheel) themselves but needs assistance putting on or taking off braces, anti-embolism hose, or orthotic shoes. These needs are captured in Module 4.8 Dressing.

**Standby assistance is defined as the need for a person to walk next to the individual in order to be readily available to help the individual in the event they fall or lose balance. In other words, the assisting person is within arm's length away in order to catch the individual if they were to lose balance and by doing so will prevent the individual from being injured.

4.11 Toileting

Definition: The ability to use the toilet, commode, bedpan, or urinal for bowel and/or bladder management. The activity of toileting consists of the following components:

• Locating the bathroom facility
• Transferring on/off the toilet, commode, bedpan, or urinal
• Maintaining regular bowel program*
• Cleansing of self
• Changing of menstrual products and/or incontinence products (if applicable)
• Managing a condom catheter or the ostomy or urinary catheter collection bag (including the emptying and/or rinsing the collection bag)
• Adjusting clothes
• Emptying the commode, bedpan, or urinal

*A regular bowel program includes using suppositories, enemas, and digital/manual stimulation with the goal of having regular bowel movements at a predictable time and frequency. This does not include the use of oral laxatives, fiber, or medications (Metamucil, Ex-lax, etc.). used by a person not on a formal bowel program.

Equipment that can be counted under toileting includes:

• Toilet grab bars/rails
• Commode
• High rise/accessible toilet
• Elevated/adaptive toilet seat
• Ostomy or catheter collection bags
• Bed pan
• Urinal
• Transfer board or other transfer aids that assist the person to get on/off the toilet

If there are interventions to prevent the incontinence (e.g., cueing or scheduled toileting) indicate the frequency of intervention being provided.

Check this for a person who:

• Requires supervision, cueing, and/or hands-on assistance (partial or complete) with any of the above mentioned components of toileting.
  
  
• Requires regular assistance or cueing to use the bathroom or would be incontinent.
  
  
• Is incontinent and requires assistance with changing incontinence pads.

Do NOT check this for a person who:

• Is incontinent and is independent with managing incontinence pads - however, select the appropriate frequency related to the person's incontinence in the sub-section dealing with incontinence.
  
  
• Only requires assistance with skilled tasks associated with ostomy or urinary catheter care (see Sections 6.14 and 6.24 in the Health Related Services Module).
  
  
• Utilizes oral laxatives, fiber, or other medications.
  
  
• Needs assistance or reminders only with flushing the toilet or the amount of toilet paper to used.

INCONTINENCE

Select the applicable level of bowel and/or bladder incontinence in this section. Urge incontinence is the sudden uncontrollable urge to frequently urinate. Do not count stress incontinence, which is leakage of urine during sneezing, coughing, or other exertion. Incontinence options include:

• Applicant does not have incontinence
• Has incontinence daily
• Has incontinence less than daily but at least once per week

If there are interventions to prevent the incontinence, e.g., cueing, scheduled toileting, indicate the frequency of intervention being provided.

Remember: If the individual has an ostomy or indwelling or straight urinary catheter, screeners should review Sections 6.14 and 6.24 in the Health Related Services Module to assure the individual's needs have been accurately identified.

4.12 Transferring

Definition: The physical ability to move between surfaces. The task of Transferring includes the ability to move from a bed, usual sleeping place, chair, to a wheelchair, or up to a standing position. Excluded from the task of Transferring is the need for assistance with a transfer to bathe or use a toilet (these needs are captured in Module 4.7 Bathing and 4.11 Toileting).

For an individual able to transfer independently, while using one of the types of equipment listed below, select 0 - Person is independent in completing the activity safely and check the corresponding box to indicate what equipment the individual uses. An example of when the selection of a 1 - Help is needed to complete the task safely but helper does not have to be physically present throughout the task, would be applicable is for a person who needs assistance at night when they are fatigued from the day, but for the rest of the day, complete all other transfers independently.

The only equipment that can be counted under Transferring includes:

• Mechanical lift or power stander
• Transfer board
• Grab bars, bed bar, or bed railing (if used for transferring)
• Trapeze
• Transfer pole

REMINDER: DO NOT count a lift chair or an electric hospital bed as a mechanical lift here. However, a screener may select a need for transfer assistance for a person who uses a lift chair or electric hospital bed, if the person is unable to transfer from the chair or bed without them. (See below)

Check this for a person who:

• Needs to wear a gait belt that is used during transfers.
  
  
• Needs hand-on assistance to complete safe transfers.
  
  
• Does not need assistance with transfers but it takes them a significant amount of time to do so and results in a significant, negative health outcome. During the task of Transferring, a significant, negative health outcome is indicated when a person experiences any of the following results: out-of-breath, dizzy, chest pains, exhausted, incontinence, or increased pain, to the point that another person should be present to help with some or all of the task.
  
  
• Needs cueing or step-by-step directions to transfer.
  
  
• Has a lift chair or other mechanical device (e.g., electric hospital bed), and cannot independently transfer without it.

Do NOT check this for a person who:

• Has a lift chair or other mechanical device (e.g., electric hospital bed), but can independently transfer without it.
  
  
• Is independent with transfers by pushing on chair arms, other furniture, wheelchair, walker, or cane.
  
  
• Is independent with transfers after rocking back and forth to gain momentum to get up from a seated position.
  
  
• Is independent with transfers but needs additional times to do so WITHOUT significant hardship or negative outcomes.
  
  
• Gets up independently when prompted.
  
  
• Requires transfer assistance getting in or out of a vehicle.
  
  
• Doesn't transfer in the home unless a family member/staff is present somewhere in the home, "just in case."

DEFINITIONS AND DISCUSSION OF IADLs

4.13 Meal Preparation

Definition: The physical and cognitive ability to obtain and prepare basic routine meals, including the task of grocery shopping. What constitutes a meal is an individual choice. Meal Preparation includes the ability to make a simple meal, such as cereal, sandwich, heat frozen foods, or reheat food prepared by others.

Meal Preparation does not include needed transportation to and from a grocery store or assistance with the money transaction to pay for the groceries. (These needs are captured in Module 4.18 Transportation and Module 4.15 Money Management.)

REMINDER: A person may request assistance with Meal Preparation due to a gender, age, or cultural norm. To select a need for assistance with Meal Preparation, a person needs to have a physical or cognitive limitation impairing their ability to complete the task independently.

REMINDER: A screener should not automatically assume assistance is needed because a person makes food choices consistent with their lifestyle and values, even if those food choices are not in agreement with professionals' advice and nutritional goals for the person.

REMINDER: When there is a need for assistance with grocery shopping only, the frequency of assistance should be selected as a 1: (Needs help from another person weekly or less often), as more frequent grocery shopping is not necessary.

The activity of Meal Preparation may include the following components:

• Open food containers
• Open the refrigerator and freezer
• Safely use their kitchen appliances
• Prepare a simple meal, such as cereal, sandwich, heat frozen foods, or reheat foods prepared by others
• Safely place food on a plate or in a cup, and carry it to a table
• Proper food preparation and storage
• Obtain groceries

The activity of obtaining groceries may include the following components:

• Selecting the food from the store shelves
• Moving items between a basket or cart to the checkout counter.
• The money transaction to pay for the groceries. (This need is captured in Module 4.15 Money Management).
• Bagging the food
• Getting the bags to a vehicle
• Getting the bags into the home
• Putting the groceries away

MEAL PREPARATION RATING SYSTEM

• 0: Independent
• 1: Needs help from another person weekly or less often
• 2: Needs help 2 to 7 times a week
• 3: Needs help with every meal

Check this for a person who:

• Has a physical or cognitive limitation impairing their ability to complete the task of Meal Preparation independently.
  
  
• Is able to independently complete the tasks involved in preparing a meal and grocery shopping but doing so results in a significant, negative health outcome. During the tasks involved in preparing a meal and grocery shopping, a significant, negative health outcome is indicated when a person experiences any of the following results: shortness of breath, dizziness, chest pains, exhaustion, incontinence, or increased pain, to the point that another person should be present to help with some or all of the task.
  
  
• Needs assistance to have food pureed, minced, thickened, or to prepare a mechanical soft diet.
  
  
• Needs assistance preparing their liquid nutrition for their tube or intravenous feedings.
  
  
• Needs assistance placing food on plate or with carrying a plate and/or cup to the table.
  
  
• Needs assistance to open food containers, even with adaptive aids (e.g., electric can opener).
  
  
• Due to a physical impairment, needs assistance opening their refrigerator or freezer, even with adaptive aids.
  
  
• Needs assistance preparing meals due to their inability to stand long enough to cook food even when taking breaks to sit down during the task of making a meal.
  
  
• Is unable to safely use at least one of their appliances to cook or heat food.
  
  
• Has Prader-Willi Syndrome.
  
  
• Needs assistance with Meal Preparation tasks due to a cognitive impairment related to their Severe and Persistent Mental Illness.
  
  
• Is unable to determine when food is spoiled.

Do NOT check this for a person who:

• Does not have a physical or cognitive limitation impairing their ability to complete the task of Meal Preparation independently.
  
  
• Chooses to only eat cold foods.
  
  
• Is able to independently complete the tasks involved in preparing a meal and grocery shopping but it takes additional time to do so WITHOUT causing significant hardship or negative outcomes.
  
  
• Needs assistance planning a menu, making a grocery shopping list, requires transportation to the grocery store, or wants to grocery shop more than once a week.
  
  
• Receives Home Delivered Meals (HDM) but is cognitively or physically able to prepare meals. There is a variety of reasons why a person may receive HDMs that do not relate to a cognitive or physical limitation to prepare meals independently.
  
  
• Can make a simple meal (cereal, sandwich, etc), can heat food (frozen, leftovers, or food prepared by others), or chooses to only eat cold foods.
  
  
• Needs to use the grocery store's scooter or wheelchair to shop.
  
  
• Needs assistance from a grocery store employee or fellow shopper to retrieve items from high or low shelves because they cannot reach the items without assistance.
  
  
• Can shop independently when their groceries are bagged in smaller and lighter bags so they can manage them.
  
  
• Chooses not to eat according to the food pyramid, eats more than three meals a day, or eats fewer than three meals per day.
  
  
• Resides in a substitute care setting or nursing home and solely because of where they reside they are not allowed to use the kitchen to prepare their meals.
  
  
• Does not prepare their meals solely because meals are provided as part of the services in the facility where they reside.
  
  
• Only needs assistance getting food out of a refrigerator or freezer located in their garage or basement.
  
  
• Can prepare a meal if they take breaks to sit down during the task.
  
  
• Is only able to cook or heat up food in a microwave oven.
  
  
• Needs assistance cleaning up after a meal. (This need is captured in Module 4.16 Laundry and/or Chores.)
  
  
• Is on a special diet (diabetic, low-cal, low-sugar, low-sodium, etc.).
  
  
• Needs to have their food pureed, minced, cut, or thickened and can do so independently with or without adaptive aids.
  
  
• Has a vision impairment that does not affect their ability to independently prepare meals.
  
  
• Needs assistance cleaning the inside of their refrigerator, including the removal of spoiled food. (This need is captured in Module 4.16 Laundry and/or Chores.)
  
  
• Receives nutrition by tube or intravenous feedings and can independently prepare their liquid nutrition.
  
  
• Has fluctuating abilities and grocery shops on their good days. For additional information on screening a person with fluctuating abilities, review Module 1.12 Strategies to Minimize Screening Limitations, D. Abilities Fluctuate.
  
  
• Could prepare meals safely and independently using a toaster oven, toaster, stove top, stove, oven, microwave oven, or electric frying pan, but they don't currently have any of these appliances.
  
  
• Needs assistance with the money transaction to pay for the groceries with cash, credit card, debit card, gift card, personal check, or by store charge account. (This need is captured in Module 4.15 Money Management.)
  
  
• Independently orders their groceries online, calls-in, or e-mails-in their grocery order for convenience.

4.14 Medication Administration and Medication Management

Definition of a Medication: A medication is a drug used to treat disease, symptoms, or injury that enters the body in the prescribed manner. The type of regularly scheduled and frequently taken medications prescribed for the person can be brand name, generic, or over-the-counter (OTC). A medication on the LTC FS must meet these three criteria:

1. Approved by the U.S. Food and Drug Administration.
   
   
2. Prescribed by a Medicaid-recognized prescriber (physician, psychiatrist, nurse practitioner, physician's assistant, optometrist, or dentist).
   
   
3. Regularly scheduled and used. Regularly scheduled medications are typically taken daily, 4 times a day, or every 8 hours.
   
   Excluded as a regularly scheduled and used medication is an as needed (PRN) medication. A PRN medication is taken only when needed based on symptoms.
   
   a.) Exception: Sliding scale insulin (where the exact dosage is adjusted according to the blood glucose level) can be treated as a regularly scheduled medication, because it is regularly given, with the dose merely adjusted to blood glucose level.
   
   b.) Exception: If a person has a standing order for a medication to be taken regularly and frequently, then it can be treated the same as a regularly scheduled medication on the LTC FS. An example of this is pain medicine ordered PRN but taken every 4 to 6 hours, every day.

REMINDER: Over-the-counter medications are included if they meet the three criteria listed in the definition of a medication.

REMINDER: On the LTC FS, a vitamin is a medication only if it is injected (e.g., vitamin B-12 injection).

A medication on the LTC FS DOES NOT include the following:

1. Vitamin (unless injected), mineral, supplement, and alternative or complementary medicines, even if prescribed by a Medicaid-recognized prescriber (physician, psychiatrist, nurse practitioner, physician's assistant, optometrist, or dentist).
   
   
2. Non-vitamin, non-mineral natural substances such as omega 3 or fish oil, glucosamine, ginkgo, anti-oxidants, ginseng, echinacea, chondroitin, coenzyme Q10, flaxseed, cranberry, garlic, soy, melatonin, green tea, saw palmetto, grape seed, milk thistle, lutein, barkwater, shark cartilage, etc., even if prescribed by a Medicaid-recognized prescriber (physician, psychiatrist, nurse practitioner, physician's assistant, optometrist, or dentist).
   
   
3. Other complementary or alternative medicines such as a homeopathic, naturopathic, or herbal therapy; or other treatment such as aromatherapy, flower remedies, crystal or magnet therapy, chelation, bowel cleansing, detoxifier, acupuncture, acupressure, etc.
   
   
4. Other dietary supplements with calories, minerals, vitamins, and/or other additives.

If the person needs someone to give them their medications, there are three general possibilities that are included under this row:

1. Medication Administration: This is a skilled task in which the nurse or someone trained by a nurse administers the medications.
    
2. Assistance with Pre-Selected Medications: An unskilled person (without the judgment about giving or holding a medication) can “assist” with medications that have been pre-selected – that is, the proper medication and dosage have been selected in advance by a pharmacist, nurse, or someone trained by a nurse. Qualifying assistance here could include a son calling his elderly mother to remind her to take her medications. Verbally cueing a person to take their medication, due to a physical or cognitive impairment, is a need for assistance with Medication Administration.
    
3. Assistance with Self-Medication: This is when a self-directing person has the cognitive ability to select the proper medication and dosage.
    

I.) MEDICATION ADMINISTRATION

Definition of Medication Administration: A person’s need for assistance from another person to take or be given a medication by any route except intravenously (IV). This could be by mouth, under the tongue, injection, onto or into the body, rectally, vaginally, or by feeding tube. The person’s need for assistance from another person in order to use a prescribed medication that is regularly scheduled and used should be captured here.

The person’s need for assistance from another person in order to use a prescribed as needed (PRN) medication, that is regularly and frequently taken, can also be treated the same as a regularly scheduled and used prescription medication, and should be captured here. Conversely, a person’s need for assistance from another person in order to use a prescribed PRN medication, that is not regularly and frequently taken, should not be captured here.
 

II.) MEDICATION MANAGEMENT

Definition of Medication Management: A person’s need for assistance from another person to set-up or monitor their prescribed and regularly taken medications.

Definition of Medication Set-Up: To separate out the proper dosage and set it aside in an assigned place for later use.

Medication set-up is completed for two reasons. One reason is to ensure the proper medication, at the proper dosage is selected when the individual is unable to select it due to a physical or cognitive limitation. The second reason is to arrange the medications to help the person remember to take them at proper times and to make it easier to tell that medications were or were not taken.

Examples of medication set-ups:

• Medication boxes with compartments labeled for different times and each day of the week, into which pills that are placed.
• Any other “set- up” system in which medications and dosages are pre-selected by another person.
• Medication dispensing machines (e.g., a CompuMed) that can be programmed (often weekly) to dispense pills.
• Pre-filling of syringes (e.g., insulin syringes).

Medication Boxes
A medication box is commonly used for convenience in organizing and remembering one's medications, even by people with no cognitive or physical impairments. When a person uses a medication box, the screener needs to determine whether due to a cognitive or physical impairment the person needs to use the medication box, and/or needs the assistance of another person to fill it.

REMINDER: The filling of a medication box should typically be indicated at the "1 to 3 times/month" frequency, since two or more medication boxes can be pre-filled at one time. If this usual method does not work well for an individual, more frequent medication set-up may be necessary.

REMINDER: Pre-filling insulin syringes can typically be completed weekly, since pre-filled syringes can be stored in the refrigerator for a week. This task should be indicated at the "Weekly" frequency.

Medication Monitoring
Medication monitoring includes two components:

1. Being cognitively capable of reporting a problem that is likely related to medication use, should it arise; and
2. The ability to collect medication-related data as ordered by the prescriber, such as vital signs, weights, blood glucose level, response to pain medications, etc. Data collection also includes in-home assistance to draw blood for a lab test.

A need for assistance with medication monitoring may be indicated when a person has an uncontrolled seizure disorder, evidenced by one or more seizures in the last six months.

Frequency of Medication Monitoring
The frequency of medication monitoring is usually lower than the frequency of medication administration.

If the person’s condition is unstable and medication is frequently adjusted, then the need for medication monitoring may be several times per week or even daily. It is expected the condition or treatment will stabilize over several weeks, and the frequency of medication monitoring will drop. A Rescreen should be completed when a person’s condition stabilizes to reflect this and other changes.

Most data collection for medication monitoring is completed less often than daily. One exception to this is blood glucose checks, which are commonly completed 3 or 4 times a day.

Pain Management
A person’s need for assistance from another person to adjust their medications, in their residence, in order to manage pain. This does not include chiropractic care, care at a pain clinic, or non-prescription medications, (e.g., an occasional Tylenol for arthritis pain).

Blood Levels
A person’s need for assistance from another person to draw blood samples, in their residence, for laboratory tests. The majority of these tasks are related to medications (e.g., Pro-Times to regulate Coumadin administration, or potassium levels for a person on diuretics). Blood levels also include “finger-sticks” for capillary blood to test blood glucose levels.

Tip: The LTC FS application will check to ensure that the level of help indicated in the IADL Medication Administration and Medication Management correlates with the Medication Administration and Medication Management tasks on the HRS Table. If the level of help does not correlate between that IADL task and the Medication Administration and Medication Management tasks on the HRS Table, the screener will receive an error message to prompt correction.
 

III.) MEDICATION ADMINISTRATION and MEDICATION MANAGEMENT RATING SYSTEM

• NA: Has no medications
• 0: Independent (with or without assistive devices).
• 1: Needs help 1 to 2 days a week or less often. Includes having someone set-up medications, pre-fill syringes, or the administration of medication.
• 2a: Needs help at least once a day 3-7 days per week--CAN direct the task and can make decisions regarding each medication.
• 2b: Needs help at least once a day 3-7 days per week--CANNOT direct the task; is cognitively unable to follow through without another person to administer each medication.

N/A: Has no medications

Check this for a person who:

• Takes no medications.
   
• Does not take regularly scheduled medication but needs assistance from another person with an infrequently taken prescription PRN medication. Such a PRN medication does not meet the LTC FS definition of a medication.
   
• Competently refuses to take any prescribed medications. In this situation, the person has no need for Medication Administration or Medication Management assistance.

0: Independent

Check this for a person who:

• Receives assistance with their prescribed and regularly taken medication but there is not a physical or cognitive impairment limiting their independence. For example, a person without a physical or cognitive impairment, who receives assistance with their medications based on an age, gender, cultural norm, or due to their facility’s licensing requirements.
   
• Takes medication as directed and has medication monitoring done outside their residence at their physician’s office, clinic, pharmacy, or health care facility.
   
• Requires Medication Administration or Medication Management assistance less often than monthly.
   
• Takes medication as directed and is able to contact the prescriber with concerns and follow their recommendations.
   
• Independently sets-up and uses their medication box.
   
• Independently uses a medication box primarily as a convenience.
   
• Is limited solely by a language barrier or illiteracy, not a cognitive or physical impairment.
   
• Is independent using adaptations such as large-print or Braille labels, “talking” glucometer, easy-open pill bottles, etc.
   
• Has an unorthodox system of organizing medications, but has no history of medication misuse or errors.
   
• Has blood drawn at their physician’s office, clinic, health care facility, or laboratory, and follows through with any changes as instructed by the prescriber.
   
• Takes medication as instructed and is able to independently check their blood glucose level, blood pressure, weights, pulse, etc.
   
• On a regular basis receives routine monitoring for general health, behavior, etc. by agency/facility staff because that monitoring is provided to all residents.
   
• Uses an automated pill dispenser (e.g., CompuMed) to independently take their medications.
   
• Needs assistance reordering or obtaining medication refills. This includes assistance to arrange for a medication refill (e.g., telephone call in request to the pharmacy, picking up the refilled medication at the pharmacy, etc.). This assistance is captured in the Laundry and/or Chores IADL (See Module 4.16 Laundry and/or Chores).
   
• Uses a lockbox to store their medication:
  • Due to the policy of their provider agency (e.g., hospice agency, personal care provider agency, etc.).
     
  • To prevent someone living with them or even a pet from having access to the medication.
     
  • Although they are not presently suicidal and are not at risk of overdosing on their medication.
     
  • Although they do not have a current substance use issue and are not at risk of taking their medication other than as prescribed.

1: Needs help 1 to 2 days per week or less often

The minimum frequency of needed assistance is once a month. A frequency less than once a month should not be indicated on the LTC FS, but could be recorded in the Notes section.

Check this for a person who:

• Due to a physical or cognitive impairment, needs someone to assist them with their prescribed and regularly taken medication (e.g., help filling their medication boxes).
   
• Has an unstable condition and medication is frequently adjusted. And, due to a cognitive impairment they need someone to monitor them for specific medication effects and side-effects and report those to the prescriber.

Do NOT check this for a person who:

• Is able to fill their own medication box(es) or could take medications without using a medication box.
   
• Takes their medication independently and does not need frequent monitoring for medication effects or side effects.
   
• Has blood drawn at their physician’s office, clinic, health care facility, or laboratory, and follows through with any changes as instructed by the prescriber.
   
• Is able to monitor and report effects and side effects themselves.
   
• Is given medication by IV only. This is captured on the IV Medications row (See Module 6.11).
   
• If the person only takes as needed (PRN) medications that are not regularly and frequently taken (e.g., aspirin or ibuprofen for occasional headaches).
   
• Has a contraception medication (e.g., Depo-Provera) injected every three months or a birth control implant (e.g., Implanon).
   
• Receives vitamin B-12 injections outside their residence (e.g., at a clinic).
   
• Is left a written reminder from another person as a cue to take their medications

2a: Needs help at least once a day 3-7 days per week-CAN DIRECT the task

CHECK this for a person who:

• Due to a physical impairment, needs someone to assist them with their prescribed and regularly taken medication.
   
• Is self-directing and has the cognitive ability to select the proper medication and dosage and also has the judgment to understand the medications’ purpose, side effects, and report problems, but needs someone to physically assist with the medication. An example of this is a person with quadriplegia who instructs their helper, “Please put 1 of those 3 pills on my tongue and give me a drink.”
   
• Needs assistance to crush their medication or assistance to put their medication in food (e.g., applesauce) in order for it to be taken.

Do NOT check this for a person who:

• Needs help taking their prescribed and regularly taken medication and is cognitively unable to instruct their helpers.
   
• Is unable to communicate in order to direct their helpers.
   
• Is non-English speaking and is unable to communicate with their helper(s) in order to direct the helper(s).
   
• Is able to take medication with less frequent assistance. An example of this is a person able to independently take their medication once another person assists them in setting up their medication box(es). In this case, select 1: (Needs help 1 to 2 days a week or less often.)
   
• Needs a call or cue from another person, to take their medication or to check if they have or have not taken their medication, if that call or cue is NOT timely enough for the person to take the missed dose. To be timely, the call or cue would typically need to be within an hour of when the dose is to be taken.
   
• Is given medication by IV only. This is captured on the IV Medications row (See Module 6.11).
   
• Is left a written reminder from another person as a cue to take their medications.

Considering 'can direct the task' versus 'cannot direct the task'
As listed on the LTC FS, the distinction between 'can direct the task' and 'cannot direct the task' applies only if the person needs help at the higher frequency of 'at least once a day 3-7 days per week.' If the person needs help less often than 3-7 days per week, the screener does not need to make a determination about the person's ability to direct the task of taking or withholding their medications.

If due to a person’s cognitive impairment, they need a cue to take their medication (within an hour of when the dose is to be taken) they cannot direct the task of managing their medication.

And, not every person with a cognitive impairment will be unable to direct the task of managing their medication. Some individuals with a cognitive limitation can independently take their medication as directed, without misuse or error, once the medication is set-up. For such a person, the selection of 1: Needs some help 1-2 days per week or less often, would be applicable.

2b: Needs help at least once a day 3-7 days per week--CANNOT direct the task

Check this for a person who:

• Due to a cognitive impairment, needs someone to assist them with their prescribed and regularly taken medication.
   
• Is not self-directing and does not have the cognitive ability to select the proper medication and dosage and also lacks the judgment to understand the medications’ purpose, side effects, report problems, and needs someone to physically assist with the medication.
   
• Needs a call or cue from another person, to take their medication or to check if they have or have not taken their medication, if that call or cue is timely enough for the person to take the missed dose. To be timely, the call or cue would typically need to be within an hour of when the dose is to be taken.
   
• Due to a cognitive impairment, needs assistance to check their blood glucose level or to adjust their insulin dose given the current blood glucose level.

Do NOT check this for a person who:

• Needs help taking their prescribed and regularly taken medication due to a physical limitation, but is able to direct helpers in selecting and taking the medication appropriately.
   
• Has a cognitive impairment but takes medication as directed, without misuse or error, once the medication is set-up.
   
• Is blind or visually impaired, if they are about to self-manage and administer their medications with reasonable accommodations (e.g., Use of Braille on a pill bottle to indicate what the medication is.)
   
• Needs a call or cue from another person, to take their medication or to check if they have or have not taken their medication, if that call or cue is NOT timely enough for the person to take the missed dose.
   
• Is given medication by IV only. This is captured on the IV Medications row (See Module 6.11).
   
• Does not have a cognitive impairment and they cannot name each of their medications, but can tell you what health issues they take medication for. Examples include but are not limited to when a person cannot name their hypertension medication (e.g., chorthalidone) but can tell you, “That little yellow pill is my water pill. I have high blood pressure.” Or, they can tell you, “I take a pill once a week for my osteoporosis.” when they are prescribed alendronate.

4.15 Money Management

Definition: The physical and cognitive ability to handle money, pay bills, and complete financial transactions needed for basic necessities (food, shelter, and clothing). These financial transactions include any of the following types of money transactions: cash, credit card, debit card, personal check, money order, automatic withdrawal, automatic deposit, or the exchange of currency.

REMINDER: A person is independent with the task of Money Management if they do not have a physical disability or cognitive impairment preventing them from learning the task. Do not indicate a need for assistance when the limitation is due to a language barrier, illiteracy, or a gender, age, or cultural norm.

REMINDER: A person without a cognitive impairment is independent with the tasks of Money Management if they manage their money consistent with their lifestyle, values, and goals, while those financial choices may not necessarily be in agreement with professionals' values or goals.

REMINDER: The selection of the frequency of needed assistance with the task of Money Management should be determined by the person's ability to manage their finances, not the frequency with which their finances are managed. For example, a person with a diagnosis of dementia and a guardian of their person lives in an Adult Family Home (AFH) and once a month, their guardian writes the needed checks for their AFH room/board, and pharmacy bill, and balances their checkbook. Although only monthly assistance is provided to manage their finances, the person's need for assistance is actually with every transaction. The screener should select option 2: [Needs help from another person daily or more often (e.g., with every transaction)].

REMINDER: Selecting 1: (Needs help from another person weekly or less often) is indicated when the person can independently handle minor money transactions and smaller amount of currency. Selecting 2: [Needs help from another person daily or more often (e.g., with every transaction)] is indicated when the person requires assistance anytime they handle money or with all of their financial matters.

MONEY MANAGEMENT RATING SYSTEM

• 0: Independent
• 1: Needs help from another person weekly or less
• 2: Needs help from another person daily or more often

Check this for a person who:

• Has a physical or cognitive limitation impairing their ability to complete the task of Money Management independently.
  
  
• Lacks or has limited fine motor dexterity.
  
  
• Has a cognitive impairment (brain injury, developmental disability, severe and persistent mental illness, or Alzheimer's disease/dementia) limiting their ability to manage their money.
  
  
• Needs assistance with the money transaction to pay for purchases with cash, credit card, debit card gift card, personal check, money order, or by store charge account.
  
  
• Needs assistance recognizing money denominations.
  
  
• Needs assistance to write a personal check or balance a checkbook, due to a physical or cognitive impairment.

Do NOT check this for a person who:

• Does not have a physical or cognitive impairment limiting their ability to complete the task of Money Management independently.
  
  
• Has inadequate income to meet their basic needs.
  
  
• Needs assistance related to a lack of experience with managing money due to their gender, age, or a cultural norm.
  
  
• Is blind or vision impaired, without assessing how they manage their money with reasonable accommodations (e.g., Use of a debit card instead of writing a check.)
  
  
• Hasn't had experience managing money and their ability to complete this task has yet to be tested. Examples of a person with the cognitive ability to manage their money, but not the experience of doing so could include but is not limited to a person: with a severe and persistent mental illness, a developmental disability, young adult, recent immigrant, or even a recent widow/widower, whose partner handled all of the couple's finances.
  
  
• Has a representative payee or money manager due to a history of poor money management related to personal choices or issues with alcoholism, a drug addiction, or a gambling addiction.
  
  
• Has a representative payee, durable power-of-attorney, power-of-attorney, authorized representative, activated power-of-attorney for health care decisions, designated power-of-attorney for health care decisions, conservatorship, or a guardian of the person and/or estate without reviewing their ability to handle at least some money transactions.
  
  
• Does not speak, read, or write English.
  
  
• Is illiterate.
  
  
• Needs transportation to the bank. (This need is captured in Module 4.18 Transportation.)
  
  
• Has a diagnosis of a cognitive impairment (e.g., brain injury, developmental disability, severe and persistent mental illness, or Alzheimer's disease/dementia) without reviewing their ability to manage their money.
  
  
• Needs assistance budgeting their income. How a person plans or doesn't plan to spend their money is not a Money Management task included in the LTC FS.
  
  
• Uses a charge account at a store (e.g., grocery store) without reviewing their ability to manage their money. The charge account may be set up as a convenience for the person paying the account's tab.

4.16 Laundry and/or Chores

Definition: The physical and cognitive ability to complete one's personal laundry, routine housekeeping, and basic home maintenance tasks, including the tasks of snow shoveling and lawn mowing.
Assistance with some Laundry and/or Chores tasks is not typically provided on a daily basis. On the rating system, a 1 would be selected for the frequency of assistance needed with the following Laundry and/or Chores tasks:

• Laundry (unless the person is incontinent and in need of more frequent laundry assistance)
• Snow shoveling
• Lawn mowing
• Vacuuming (unless the person has a documented medical reason and need for more frequent vacuuming)
• Floor washing (unless the person has incontinence or other documented medical reason and is in need of more frequent floor washing)

REMINDER: Screeners need to acknowledge the person's lifestyle choices, values, and goals related to their level of laundry and/or household cleanliness may not necessarily be in agreement with the professionals'.

REMINDER: The frequency of needed assistance with the tasks of Laundry and/or Chores is to be based on need, not the availability of staff to assist the person.

LAUNDRY AND/OR CHORES RATING SYSTEM

• 0: Independent
• 1: Needs help from another person weekly or less often
• 2: Needs help more than once a week

Check this for a person who:

• Has a physical or cognitive limitation impairing their ability to complete their laundry and/or household chores.
  
  
• Is able to independently complete the tasks involved in completing their laundry and/or household chores but doing so causes a significant, negative health outcome. During the tasks involved in completing their laundry and/or household chores, a significant, negative health outcome is indicated when a person experiences any of the following results: shortness of breath, dizziness, chest pains, exhaustion, incontinence, or increased pain, to the point that another person should be present to help with some or all of the task.
  
  
• Hoards personal items or food and this behavior creates a potential health or safety issue.
  
  
• Needs assistance cleaning up after a meal.
  
  
• Needs assistance cleaning the inside of their refrigerator.
  
  
• Needs assistance to re-order medications.

Do NOT check this for a person who:

• Does not have a physical or cognitive limitation impairing their ability to complete their laundry and/or household chores.
  
  
• Is able to independently complete the tasks involved in completing their laundry and/or household chores but it takes additional time to do so WITHOUT causing significant hardship or negative outcomes.
  
  
• Needs assistance with window washing, gardening, weatherization, grooming the yard (including weeding, pruning hedges, raking leaves, and aerating or fertilizing the grass).
  
  
• Needs housecleaning assistance more than weekly due to having a pet(s) in their home and has related allergies.
  
  
• Needs assistance with home repairs that are beyond basic cleaning but enhance the dwelling's appearance (e.g., painting).
  
  
• Resides in a residential facility or institution and the provision of Laundry and/or Chore services is provided as part of the facility package, without reviewing their need for assistance with these tasks.
  
  
• Needs assistance completing other household members' laundry (e.g., spouse's or children's laundry) or the cleaning of living spaces not used by the individual (e.g., teenager's bedroom or bathroom).
  
  
• Needs assistance with heavy-duty cleaning done infrequently, such as carpet, drapery, and window cleaning or wall washing.
  
  
• Needs assistance related to a lack of experience completing their laundry and/or household chores due their age, gender, or cultural norm and does not complete these tasks.

4.17 Telephone

Definition: The physical and cognitive ability of a person to use their personal telephone to make and receive a routine telephone call with or without assistive devices. What constitutes a routine telephone call is very person-specific. They are the familiar and frequent telephone calls a person makes and receives.

The ability to use the telephone does not include the assistance a person may need to make or receive a non-routine telephone call. The need for assistance with non-routine telephone calls is captured in the Cognition for Daily Decision Making task in the Communication and Cognition Section of the LTC FS.

Examples of non-routine telephone calls can include but are not limited to a person's need for assistance making an appointment with the Income Maintenance Unit for an annual financial review; making an appointment with a health care specialist every three months, or responding to their doctor's office sporadic calls to change an appointment time.

TELEPHONE RATING SYSTEM

• 1a: Independent. Has cognitive and physical abilities to make calls and answer calls
• 1b: Lacks cognitive or physical abilities to use phone independently

  -and-

• 2a: Currently has working telephone or access to one
• 2b: Has no phone and no access to phone

1a: Independent. Has cognitive and physical abilities to make calls and answer calls.

Check this for a person who:

• Needs assistance with a telephone other than their personal telephone, but can independently use their personal telephone.
  
  
• Independently uses a telephone with preprogrammed numbers or list of frequently called numbers.
  
  
• Independently uses a telephone with an assistive device or with assistance from a telecommunications relay service.
  
  
• Does not have a landline, but does use a cell phone.
  
  
• Does not speak or understand spoken English.
  
  
• Does not use a telephone due to their age, gender, or cultural norm.
  
• Needs assistance with non-routine telephone calls.

1b: Lacks cognitive or physical abilities to use phone independently.

Check this for a person who:

• Would be independent with this task if they used an assistive device, but they don't currently have it. A person's untried potential for using an assistive device should not be considered when assessing the person's current need for assistance.
  
  
• Will answer a ringing telephone but is not able to place a call.
  
  
• Is hard of hearing, deaf, or has a speech impairment, and does not have a teletypewriter (TTY) or other adaptive device to use with their telephone.
  
  
• Is unable to make themselves understood due to significant communication impairment (e.g., aphasia).

4.18 Transportation

Definition: At the time of the screening, the person is physically and cognitively capable of driving a regular or adapted vehicle.

TRANSPORTATION RATING SYSTEM

• 1a: Person drives regular vehicle
• 1b: Person drives adapted vehicle
• 1c: Person drives regular vehicle, but there are serious safety concerns
• 1d Person drives adapted vehicle, but there are serious safety concerns
• 2: Person cannot drive due to physical, psychiatric, or cognitive impairment
• 3: Person does not drive due to other reasons

A regular vehicle is a standard model vehicle the person operates without needing specialized adaptations to drive.

A regular vehicle may be equipped with modifications that allow the person to enter/exit the vehicle or allow their mobility device to be transported with them. While these modifications may be needed in order for the person to RIDE in the vehicle they are not necessary for the person to operate the vehicle.

Examples of vehicular modifications include, but are not limited to, a car top carrier for a wheelchair, trunk lift for carrying a wheelchair or scooter, grab bar, automatic door opener, van lift used to enter/exit the van when sitting in a wheelchair or scooter, etc.

For the purposes of the LTC FS, a vehicle with these and similar modifications is not an adapted vehicle.

Select 1a: Person drives regular vehicle if they are able to drive a vehicle with or without modifications described above.

An adapted vehicle is one the person operates that has after-market specialized equipment making the vehicle accessible for the person to DRIVE; without the specialized adaptations, the person would not be able to drive the vehicle.

These adaptations help the driver control the vehicle's speed and direction and may include, but are not limited to, hand controls, adaptive pedal extensions, switch pad controls, extended gearshift handle, etc.

Select 1b: Person drives adapted vehicle if they are only able to drive a vehicle that has specialized and adaptive driving equipment described above.

Serious Safety Concerns
Serious safety concerns may be evident when a person with a physical, psychiatric, or cognitive impairment drives a motor vehicle. The screener will rely on professional judgment when reviewing how limitations may affect the person’s ability to safely drive a vehicle.

Some examples of a person driving with serious safety concerns can include but are not limited to a person who drives:

• With a diagnosis of dementia.
• With impaired vision.
• With paresis without using specialized equipment.
• Under the influence of alcohol or a controlled substance.

REMINDER: Do not select 1b: Person drives adapted vehicle, when the person could drive an adapted vehicle but does not currently have the needed specialized equipment in their vehicle.

Select 1c: Person drives a regular vehicle, but there are serious safety concerns; if they have a diagnosis, condition, or driving history described above and they drive a regular vehicle.

Select 1d: Person drives adapted vehicle, but there are serious safety concerns; if they have a diagnosis, condition, or driving history described above and they drive an adapted vehicle.

Serious safety concerns should not be selected for a person who has made a reasonable accommodation(s) that limits driving to:

• Only during daylight hours.
• Non-rush hours (typically weekdays, 9:00 a.m. to 3:00 p.m.).
• Neighborhood driving.
• Only short distances from their residence.
• Comply with the Division of Motor Vehicles (DMV) restrictions on their license.
• Comply with the limits associated with their occupational license.

Select 2: Person cannot drive due to physical, psychiatric or cognitive impairment; if at the time of the screening, the person does not drive or is not capable of driving due to a physical condition (e.g., blindness or hemiparesis); psychiatric condition (e.g., schizophrenia), or cognitive impairment (e.g., dementia).

Select 3: Person does not drive due to other reasons; if at the time of the screening, the person does not have a physical, psychiatric, or cognitive impairment limiting their ability to drive, but the only reason they do not drive is because the person:

• Never learned to drive.
• Lacks a valid driver license due to a reason other than a physical, psychiatric, or cognitive impairment.
• Does not own a vehicle or have access to one.
• Cannot afford to maintain a vehicle.
• Cannot afford vehicle insurance coverage.
• Only utilizes mass transit or taxi service.
• By choice, is only driven by family members or friends.
• Adheres to an age, gender, or cultural norm.

4.19 Overnight Care or Overnight Supervision

The need for Overnight Care or Overnight Supervision is not an ADL or an IADL task but is included in this Module. To select a need for Overnight Care or Overnight Supervision, the individual must have a physical or cognitive limitation impairing their ability to independently complete overnight care tasks or have a limitation requiring overnight care or overnight supervision.

Overnight Care is defined as the need for hands-on assistance or verbal cuing from another person, to complete an ADL or Health Related Services task, during the overnight hours.

Overnight Supervision is defined as the need for someone to be present to prevent, oversee, manage, direct, or respond to a person's disruptive, risky, or harmful behaviors, during the overnight hours. Overnight Supervision is indicated for a person unable to respond appropriately in an emergency (e.g., a vulnerable adult).

Overnight Supervision is not indicated for a person without a physical or cognitive limitation who is uneasy being alone at night.

All people currently residing in ICF-MRs, nursing homes, or residential care facilities DO NOT necessarily require Overnight Care or Overnight Supervision. You should ask yourself, "Would this person require overnight care or overnight supervision were they not residing in an institutional or residential care facility?" Ask the facility's staff whether the person being screened has ever demonstrated a need for assistance during the night shift. Does the person need to use the call button for staff at night? Or rather, does the person independently get to and from the bathroom at night?

REMINDER: Although licensed facilities have policies that require staff to monitor the residents at night, overnight care or overnight supervision is not necessarily needed by each resident.

OVERNIGHT CARE or OVERNIGHT SUPERVISION RATING SYSTEM

• 0: No
• 1: Yes; caregiver can get at least 6 hours of uninterrupted sleep per night.
• 2: Yes; caregiver cannot get at least 6 hours of uninterrupted sleep per night.

Check this for a person who:

• Needs help overnight from another person due to a physical or cognitive limitation jeopardizing their health and safety during that time.
• Competently chooses to be alone overnight, although they have a physical limitation typically requiring overnight care or overnight supervision (e.g., a need for assistance with transfers). Although the person is competently refusing the care or supervision, the need for the assistance still exists.
• Has limited cognitive abilities and needs Overnight Supervision, although they do not need Overnight Care.
• Has disruptive or risky nighttime behavior that requires intervention.
• Has an uncontrolled seizure disorder, evidenced by one or more seizures in the last six months.
• Lives independently without assistance during the daytime, but requires intervention or supervision during the nighttime due to an unstable mental health condition (e.g., Post Traumatic Stress Disorder).
• Can safely get through a day without needing a cue or reminder, is able to make safe routine decisions, but does not have the cognitive capacity to know when to call for help and requires assistance in an emergency such as a flood, fire, or tornado.
• Has a monitoring system with an onsite or offsite response person and in the last six months the system's intervention was initiated in response to a need, at least once (e.g., WanderGuard or Sound Response System).
• Has a need for a room-to-room monitor, bed alarm, or door alarm system with an onsite or offsite response person.
• Has a Personal Emergency Response System (PERS) and during the nighttime hours uses it to summon assistance with a physical care need.

Do NOT check this for a person who:

• Does not have a physical or cognitive limitation jeopardizing their health and safety overnight.
• Desires overnight care or overnight supervision based solely on an age, gender, or cultural norm.
• Receives overnight care or overnight supervision but does not have an identified physical or cognitive limitation requiring that care or supervision. For example, a family member is uncomfortable with the person being alone at night, the person's roommate requires overnight care or overnight supervision, or the person is up during the nighttime hours without a need for care or supervision.
• Has a Personal Emergency Response System (PERS) and only uses it as a means of accessing assistance in the event of an emergency. The presence of a PERS alone does not by itself indicate a need for Overnight Care or Overnight Supervision.
• Has a controlled seizure disorder, evidenced by no seizures in the last six months.
• Has a cognitive impairment without a physical limitation and can safely get through a day without needing a cue or reminder. Additionally, the person is able to make safe routine decisions and has the cognitive capacity to know when to call for help, and only requires assistance in an emergency such as a flood, fire, or tornado.
• Has a cognitive impairment and a safety plan they can articulate, which indicates they know how to respond appropriately in the event of an emergency.
• Has a specific diagnosis. A need for Overnight Care or Overnight Supervision is not based solely on the person's diagnosis.
• Lives in a residential care setting, ICF-MR, or nursing home where overnight care or overnight supervision are provided based on facility policy and the person does not have an assessed need for those services.
• Lives in a residential care setting with 'sleep staff,' which refers to staff able to get at least 6 hours of uninterrupted sleep per night although this person does not need Overnight Care or Overnight Supervision.
• Lives in a residential care setting with 'awake staff,' which refers to staff unable to get at least 6 hours of uninterrupted sleep per night, although this person does not need Overnight Care or Overnight Supervision.
• Has a monitoring system with an onsite or offsite response person and in the last six months the system's intervention was NOT initiated.
• Needs monitoring overnight related to their use of the Internet.

4.20 Employment

This section concerns the need for assistance to perform employment-specific activities (job duties). Since a person's need for help with ADLs and other IADLs (e.g., transportation, personal care) is captured in other sections, this section essentially concerns supports necessary for successful performance of work tasks.

The screener should clearly inform the person they are screening that responses to the employment questions will not detract from their eligibility for Social Security, Medicaid, long-term care, or other benefits.

EMPLOYMENT RATING SYSTEM

A. Current Employment:

• 1  Retired (Does not include people under 65 who stopped working for health or disability reasons)
• 2  Not working (No paid work)
• 3  Working full time (Paid work averaging 30 or more hours per week)
• 4  Working part-time (Paid work averaging fewer than 30 hours per week)

B. If Employed, Where:

• 1  Paid work where the environment and the work tasks are designed for people with disabilities (e.g., sheltered workshop)
• 2  Paid work in other group situation for people with disabilities (e.g., work crew/enclave)
• 3  Paid work outside the home (situations other than those described in B1 and B2)
• 4  Paid work at home

C. Need for Assistance to Work (Mandatory for ages 18-64; otherwise optional):

• 0  Independent (with assistive devices if uses them)
• 1  Needs help weekly or less (e.g., if a problem arises)
• 2  Needs help every day but does not need the continuous presence of another person
• 3  Needs the continuous presence of another person
• 4  Not applicable (please explain)

A. CURRENT EMPLOYMENT STATUS

Choose one option that best describes the individual's status:

1:  Retired (Does not include people under 65 who stopped working for health or disability reasons)

• Check this for a person who:
  • Is age 65 or older and is not in the workforce (whether receiving retirement benefits or not).
  • Is under age 65, receiving retirement benefits, and did not stop working because of a health problem or a disability.
    
    
• Do NOT check this for a person who:
  • Stopped working before age 65 due to a health problem or a disability, even if the person describes it as an "early retirement." Instead, check 2: Not working (No paid work).
  • Is involved in unpaid pre-vocational activities only. Instead, check 2: Not working (No paid work).

2:  Not working (No paid work)

• Check this for a person who:
  • Is under age 65 and is not working for pay for any reason (unless retired).
  • Is under age 65 and stopped working due to a health problem or a disability.
  • Is involved in unpaid pre-vocational activities.
  • Is involved in volunteer activities (including volunteer and in-kind work to meet Medicaid Purchase Plan (MAPP) eligibility requirements).
    
    
• Do NOT check this for a person who:
  • Is over age 65 and is not working for pay. Instead, check 1: Retired (Does not include people under 65 who stopped working for health or disability reasons).

3: Working full time (Paid work averaging 30 or more hours per week)

• Check this for a person who:
  • Is earning income for working, on average 30 hours per week or more.
  • Is earning income at facility-based employment on average 30 hours per week or more. This includes pre-vocational activities if paid, on average 30 hours per week or more.
  • Is earning income through supported employment or work crew/enclave if paid on average 30 hours per week or more.
    
    
• Do NOT check this for a person who:
  • On average, is paid for fewer than 30 hours per week. Instead, check 4: Working part-time (paid work averaging fewer than 30 hours per week).
  • Attends a facility-based pre-vocational program (e.g., sheltered workshop) but is not participating in paid work for 30 hours per week or more.

4: Working part-time (Paid work averaging fewer than 30 hours per week)

• Check this for a person who:
  • Is earning income for working, on average, fewer than 30 hours per week.
  • Is earning income at facility-based employment, on average, fewer than 30 hours per week. This includes pre-vocational work if paid, on average, fewer than 30 hours per week.
  • Is working facility-based employment and is paid by piece-rate not hourly, on average, is paid fewer than 30 hours per week.
  • Is earning income through supported employment or work crew/enclave paid hours and is paid, on average, fewer than 30 hours per week.
    
    
• Do NOT check this for a person who:
  • Is not working for pay.
  • On average, is paid for 30 or more hours per week of work. Instead, check 3: Working full time (Paid work averaged 30 or more hours per week).

Note: In sheltered workshops, wages are often paid by piece-rate rather than hourly. The screener only needs to determine if the time involved working for pay is fewer than 30 hours per week. This is most common. Typical full time program attendance is 30 hours per week; not all hours are typically paid, so paid hours are usually fewer than 30 hours per week.

B. IF EMPLOYED, WHERE

Skip this section if in Section A, 1: Retired or 2: Not Working was selected. 

Check all that apply, as some individuals work in more than one type of employment location.

1:  Paid work where the environment and the work tasks are designed for people with disabilities (e.g., sheltered workshop)

This item includes paid work in a sheltered workshop, also known as a community rehabilitation program (CRP), work center, or facility-based employment. These entities are distinguishable from mainstream employers by the fact that the primary mission of the corporation/entity is to provide services to individuals with disabilities and they typically employ a large number of individuals with disabilities in one or more departments or divisions. These entities are typically licensed to pay sub-minimum wages to a group of workers with disabilities. Most provide other rehabilitation and long-term support services besides employment, including day services, therapies, and transportation.

2: Paid work in other group situation for people with disabilities (e.g., work crew/enclave)

Work crews and enclaves are group employment arrangements where two or more individuals with disabilities work in a team to perform work that is typically sub-contract work in a community setting. The employer of record is typically the support provider agency (e.g., sheltered workshop/community rehabilitation facility/work center). Because people with disabilities are grouped together, this is considered segregated employment, not community-integrated employment, even if the work crew or enclave does its work in a community setting.

3: Paid work outside the home (situations other than those described in B1 and B2)

This is work an individual does that is not done in a sheltered workshop or in the individual's home, and which is not done as part of participation in a work crew or enclave. In other words, a paid job in the community is any work done for pay that does not fall into one of the other three categories. This includes supported employment, as well as working independently.

4: Paid work at home

This is work an individual does in his/her place of residence, or in an office/work area attached to, or on the grounds of, his/her place of residence.

C. NEED ASSISTANCE FOR WORK

This item is optional for people age 65 or older or under age 18.

This item is mandatory for people aged 18-64, even if the person is not currently working.

Choose one option that best describes the individual's current or anticipated need.

• 0:  Independent (with assistive devices if uses them)
• 1:  Needs help weekly or less (e.g., if a problem arises)
• 2:  Needs help every day but does not need the continuous presence of another person
• 3:  Needs the continuous presence of another person
• 4:  Not applicable (Please explain)

Predicting the need for assistance to work for those not currently working
If the person is not currently working, the screener will need to estimate the level of help the person would likely need to work. This is can be deduced from the person's overall functioning and abilities. The screener should consider other information such as the frequency of help needed at home; cognition for daily decision making; IADLs; ADLs and other physical activities, behavioral supports, and skilled nursing needs. The presence of a particular type of disability or health disorder (e.g., cognitive disability; seizures) or guardianship does not automatically mean an individual will need the continuous presence of another person in order to work.

To decide which of the five answer choices best represents the level of help needed to work, the screener should follow these steps:

1. If the person worked before and their work abilities are unchanged, indicate the level of job help needed in the past.

2. Deduce from the level of supports indicated elsewhere in the LTC FS:

• Cognition for Daily Decision Making
• Communication impairments
• Behavioral interventions
• Assistance with ADLs and IADLs
• Health care tasks (blood sugar checks, catheters, repositioning, etc.).

3. Consider other factors not captured elsewhere on the LTC FS that create the need for employment supports. Examples include learning disorders, mental health or behavioral challenges, language barrier, or the need for job training or supervision not related to long term care needs.

4: Not Applicable

• Should only be selected if the person is severely ill or in a semi-comatose state. Severe disabilities in themselves do not render a person unable to work. For a person with marked cognitive and/or physical disabilities, the screener should consider whether selection of 1, 2, or 3 is the most accurate choice.
  
  
• Should not be selected simply because the person is not interested in seeking employment. Even if the person is not expected to seek employment in the near future, the screener should estimate the level of assistance that would be needed if the person did begin work.
  
  
• Explain in the notes section why it is unreasonable to consider employment for this working-age person, even with continuous assistance from another person.

Last Revised: April 18, 2013
Wisconsin Department of Health Services
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