Home and neighborhood assessment

Patient Name:Date:

Criteria selection for home visits

Check yes / Unknown or not sure / Demographic, socioeconomic and clinical factors:
Age=>75
< high school education
Low health literacy
Low income
=>2 chronic conditions
=> 5 medications
Medication nonadherence
Lack social support
Psychosocial stress:
Other:

Housing (check is data is availableand provide details as indicated)

Apartment (how many units in building, how long and monthly rental)
Home (year built and mortgage):
How many bedroom and bathroom?
Number of occupants:
Deteriorating appearance (wall cracks, gutter down spouts)
Leaking roofs, stained ceilings
Unsafe steps, no banister rails, steps not demarcated
Type of heating system and use of portable space heaters:
Smoke detectors, carbon monoxide detectors and batteries:
Cooking appliance:
Flooring (old rug, broken tile, hard wood floor, clutters):
Is lighting adequate? (location of light switches, night lights, stairs lighted)
Any outlets overloaded? Electrical cords as fall/fire hazard
Communication (landline, mobile, internet connection):
Kitchen and bathroom unvented
Food in refrigerator:
Bathroom: toilet seat, grab rails, non-skid strips/mat, shower chair, urinal, bedside commode?
Location of medication bottles (pillbox?); old medication bottles around?
Furniture easily tipped over or hard to get in/out of
Dust and/or mold in the home
Exposure to second-hand smoke
Porches in poor condition
Broken windows/doors/screens
Yard not kept, overgrown weeds/plants, trash
Other:

Neighborhood (check yes if able to assess and elaborate as indicated)

Location and history (including age structure of inhabitants):
Distance to B’ham clinic, PCP and Oakland:
Major housing issue in the neighborhood:
Neighbor who could help in times of need:
Public transportation (bus route):
Cracked sidewalks, walkability:
Vacant storefronts, abandoned buildings, closed stores:
Streetlamps
Traffic lights/yield signs/pedestrian islands:
Police presence
Schools:
Grocery stores (convenience, full-service, distance from home)
Pharmacies
Banks/credit unions/check-cashing services
Park availability and perception of park safety
Recreational facilities:
Laundromats
Places of worship, senior center, social clubs?
Other:

Describe the patient’s daily activities in a typical day:

AM: wake up time, breakfast, work, home, go out, etc.

PM: lunch, naps, coming home, exercise, etc.

Evening/night: dinner, TV, socializing, sleep, etc.

Weekends:

Patient’s life goal and aspiration:

Interventions

Priority / Problem (category) / Action plan by patient / Action plan by healthcare team
Lack of social support
Health Literacy
Unhealthy housing condition (list):
Access to healthy food and conditions for healthier eating
Resources and facilitators to increase physical activity
Income and benefits
Legal issues
Other issue:

Additional comments: