MD TELEPHONE SCREEN: ITEM BY ITEM GUIDE

This document provides guidance for individuals who will be involved in the pilot test of the Maryland telephone screen. All items used here, with the exception of those with an asterisk at the end of the item, are abbreviated versions of the same items from the interRAI Home Care assessment instrument. While they seek the same information, they have been rewritten for use as a telephone screen and are generally less detailed. If you would like more information about an item, consult the interRAI user manual.

Ask items in a conversational manner to help put the person at ease. (In everyday use, after the screener becomes familiar with the items, they can be asked when the appropriate subject comes up in a conversation.) There is no need to ask an item if the person clearly provides the information in the course of conversation.

Keep re-phrasing of items to a minimum to insure consistency. Be patient. If the person doesn’t respond, acknowledge this by asking if the person would like you to re-state the item. Also ask whether the person can hear you adequately.

In cases where the person is unable/unwilling to take part in the screen, speak to the main unpaid helper if at all possible.

Fill out the feedback items for each screen; these are important to the research effort. Be sure to note the time you begin each screen so you have an accurate estimate of the duration of the screening.

Thanks to the South Dakota Department of Social Services for sharing a version of this screen guide.

To be determined before performing screen:

  1. Does thecaller have any history of mental illness?

Note: Mental illness includes any concerns about emotional wellnessthat interfere with quality of life or daily functioning. This includes depression, anxiety, psychosis, loss of interest in daily activities, etc.

  1. No
  2. Yes

2. Does the caller have any history of abusing alcohol or drugs?

Note: Substance abuse includes any use that interferes with quality of life or daily functioning and reports that others have advised them to seek help for addictions.

  1. No
  2. Yes

3. Does the caller have any history of brain injury?

Note: Brain injury is indicated by a report of a blow to the head, being "knocked out," a concussion, lost consciousness, or being in a coma following an injury (motor vehicle or bicycle accident, fall, assault).

  1. No
  2. Yes
  1. Does the caller have any history or diagnosis of developmental or intellectual disability?
  1. No
  2. Yes

5. Has the caller ever served in the military?

0. No

1. Yes

Script:

I’d like to have a conversation with you to find out how you do everyday tasks and to learn more about your health. This will take about fifteen minutes. It’s important that you tell me how things really are going for you, as accurately as possible, so I can make sure you get the kind of assistance that will best meet your needs.

First, I’d like to understand more about your ability to do some everyday tasks. I’m interested in your ability to do these tasks, not whether you actually did them.

1. In the last three days, were you able to go shopping, including selecting items

to buy and paying for them? (Exclude transportation.)

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

Set-up help only: Making a list of needed items, provides the checkbook or needed cash to the person and the person then independently shops.

Supervision-oversight, cueing: Being with the person to point out needed items, reminding him/her how to write out the check and to write the amount in the checkbook

More assistance needed: Writing the check for the person, selecting the food items, etc.

2. In the last three days, were you able to prepare meals?

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

Set-up help only: Setting out meal ingredients or the food that the person will heat up on his/her own

Supervision-oversight, cueing: Prompting the person during the meal preparation; assuring the stove/oven/microwave is used in a safe manner and turned off after the meal is cooked/heated; reminding the person to refrigerate perishable items

More assistance needed: Mixing the ingredients together, cooking the meal

Note: Receiving home delivered meals (through a nutrition site or from a family member or a using a TV dinner) does not mean the person is unable to prepare his/her meals. How the person heats up the meal is a consideration for such instances.

3. In the last three days, were you able to drive yourself, get in or out of a car,

or use public transportation?

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

Set-up help only: Arranging for transit service or other transportation (and then the person is able to independently access transit or other transportation)

Supervision-oversight, cueing: A helper remains nearby to make sure the person gets into and out of the vehicle, guiding or guarding without physical assistance or with minimal or intermittent physical contact

More assistance needed: Physical support getting into and out of the vehicle

4. In the last three days, were you able to do work around the house, like

doing dishes, making the bed, doing laundry, or straightening up?

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

Set-up help only: Getting out cleaning supplies and the person independently completes the task

Supervision-oversight, cueing: Writing a list of tasks to be completed, prompting the person to complete the task and stay on task; verbal reminders with certain tasks

More assistance needed: Physical assistance to help person perform or complete tasks

5. In the last three days, were you able to manage use of the phone?

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

6. In the last three days, were you able to manage your medications?

(Includes remembering when to take pills, opening the bottles, and taking the right dosages.)

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

Set-up help only: Setting out/opening medication bottles or placing medication in a cup or pill minder, writing a list of medications to take and when to take the medication

Supervision-oversight, cueing: Reminding the person to take the medication and assuring the person takes the medication; use of an electronic pill dispenser (a helper sets the medication time (s) and the person takes the medication when alarm reminds the person) More assistance needed: Administer the medications, ensure medications are swallowed

7. In the last three days, were you able to manage your finances, like

paying bills, balancing your checkbook, or checking your credit card balance?

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

Set-up help only: Setting out bills to be paid; providing a calculator, checkbook, pen, etc.

Supervision-oversight, cueing: Reminding the person which bills should be paid, cueing about how the checks should be written

More assistance needed: Writing the checks, arranging for bill pay, balancing the checkbook

SCRIPT: Now I’d like you to tell me about what you have done recently. I want to know what you have actually done by yourself, or others have done for you, NOTwhether you are able to do these activities.

  1. In the last three days, how much have you engaged in any physicalactivity, such as walking, cleaning the house, or exercising?

0. More than 2 hours

1. Not performed or performed 2 hours or less

Considerations: The accumulated time in the three days; the time does not have to occur all at once on a given day.

9. In the last three days, has your condition required that meals be prepared

FULLY by others?

0. No

1. Yes

2. Activity did not occur

.

10. In the last three days, what assistive devices have you used to move

around indoors?

0. No assistive device

1. Cane or walker

2. Wheelchair or scooter

3. Activity did not occur

Independent-no help, set-up, or supervision: The person performed the activity or task alone, without help, set-up or supervision.

Set-up help only: The person is provided with materials, devices, or preparation to perform an activity independently. Includes giving or holding out an item that the person takes and the helper then leaves the person alone to complete the activity.

Supervision-oversight, cueing: If the helper remains nearby to watch over the person; if the helper provides prompts to the person, i.e., “take a bite”, “slow down”, “don’t forget to rinse your hair,” etc.

More assistance needed: If the helper provides more assistance than set-up help or supervision-oversight, cueing.

Activity did not occur: The activity was not performed.

11. In the last three days, what kind of help did you get to move around

indoors? (Note: if person used a wheelchair, score for self-sufficiencyonce in

wheelchair.)

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

4. Activity did not occur

Set-up help only: Handing the person a walker or cane; positioning walker or wheelchair within easy access for the person to use the assistive device

Supervision-oversight, cueing: Remaining nearby to watch over the person or guide movements

More assistance needed: Providing support by holding person under armpit or allowing person to lean on arm

12. In the last three days, what kind of help did you get to dress yourself?

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance used

4. Activity did not occur

Set-up help only: Picking out the clothes; placing the person’s clothes out for them to put on; holding out the shirt or clothing article for the person to take – and then leaving the person alone to dress themselves

Supervision-oversight, cueing: Remaining nearby to watch over the person; reminding the person to put on certain articles of clothing or to button the clothing

More assistance needed: Physically helping the person put on the clothing and helping with the buttoning or snapping of clothing; completing pulling up the person’s pants or repositioning clothing articles

13. In the last three days, did you use any help to use the toilet?*

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance used

4. Activity did not occur

14. In the last three days, did you use any help to move around in bed?

(Includes moving to and from a lying position to a sitting position, turning from side to side, and repositioning body while in bed)

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance used

4. Activity did not occur

Independent: Includes use of a trapeze that is suspended from a frame which may be freestanding or attached to the bed to move around in bed.

Set-up help only: Turning down the bed covers

Supervision-oversight, cueing: Guiding the person to a lying position with minimal physical

contact or intermittent physical guarding

More assistance needed: Holding the full weight of the arm and/or back to move to and from

the lying position; fully positioning the body in bed; physically turning the person during

resting or sleeping time.

15. In the last three days, did you use any help to bathe, shower, or

take a sponge bath?

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

4. Activity did not occur

Set-up help only: Providing the person with bathing article (s) (soap, washcloth, towels, etc.) so the person performs independently. This includes giving or holding out an item that the person takes from another person and the person leaves the person alone to complete the activity

Supervision-oversight, cueing: If someone remains nearby to watch over the person, cueing for the activity, and/or guiding or guarding the person with minimal physical contact

More assistance needed: Assisting the person to raise an arm; weight bearing assistance in or out of tub.

16. In the last three days did you use any help to transfer from one position to

another? (Includes moving from bed to chair or wheelchair, or rising out of a chair

to a standing position.)

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

4. Activity did not occur

Independent: Includes when a person uses a lift chair to get to a standing position.

Set-up help only: Handing the person a walker, cane, etc; positioning an assistive device or furniture within the person’s reach.

Supervision-oversight, cueing: Remaining nearby to guide or guard the person with minimal or intermittent physical assistance

More assistance needed: Taking the person’s full weight by holding him/her under the armpit or allowing the person to lean on another person’s arm

Note: This item does not include transfer to or from the toilet.

17. In the last three days did you use any help to eat?

(Includes taking in food by any method, including tube feeding.)

0. Independent—no help, set-up, or supervision

1. Set-up help only

2. Supervision—oversight, cueing

3. More assistance needed

4. Activity did not occur

Set-up help only: Cutting up food into bite size pieces; opening containers

Supervision-oversight, cueing: Prompting or reminding the person to slow down, to chew food, to take smaller bites of food, to swallow food

More assistance needed: Physically helping the person to eat, e.g., spoon feeding the person his/her food

SCRIPT: Next, I’d like to learn more about your living arrangements.

18. Are there any hazards that make it difficult for you to enter, move around in, or leave your home?

0. No

1. Yes

Considerations:

  • Difficulty entering or leaving the home
  • Difficulty maneuvering within rooms
  • Includes physical problems that limit access: weak or broken stairs; loose or missing stair railings entering the home or within the home; only entrance/exit has stairs; no ramp/lift
  • Carpeting prevents person using walker or cane from moving around in home
  • High thresholds or narrow doorways prevent movement

19. In the last 90 days, have you moved in with others, or have others moved in with you?

0. No

1. Yes

20. In the last three days, have you been left alone in the morning or afternoon?

0. No—person is never or hardly ever left alone

1. Yes—person is left alone, even if only for about one hour

Considerations:

  • Person is literally alone, without anyone else in the home
  • If in congregate housing or other situation where others are present, time person spends by himself/herself in his/her own room

21. Do you, or does your main helper, if any, believe that you would be better off elsewhere?

0. No

1. Yes

Considerations:

  • Would the person be happier living somewhere else?
  • Would the person be less isolated living elsewhere?
  • Would the person’s needs be met better?
  • Would the person feel safer?

SCRIPT: Now I’d like to ask you a few questions about your health.

  1. In the last three days, have you had a flare up of a recurrent or chronic

Health problem?

0. No

1. Yes

23. In the last three days, have you had any troubling skin conditions,

such as burns, tears, open lesions, bruises, or rashes?

0. No

1. Yes

  1. In the last three days, have you received any of the following care:
  1. Care of a wound or pressure ulcer, or moving/turning to

prevent skin breakdown?

0. No

1. Yes

A pressure ulcer is any lesion caused by unrelieved pressure. Pressure ulcers usually occur over bony prominences (heel, elbow, knee); an area of skin that appears continually reddened; an abrasion, blister, or skin crater.

b. Home care aide

0. No

1. Yes

Any paid staff who provides “hands-on” ADL support and monitoring of health status.

c. Physical therapy

0. No

1. Yes

Physical therapy services are provided or directly supervised by a qualified physical therapist. A qualified physical therapy assistant may provide therapy.

d. SOCIAL WORKER

0. No

1. Yes

  1. Monitoring by a nurse?

0. No

1. Yes

Monitoring by a licensed or registered nurse who provides assessment of person’s health status.

f. Treatment with IV (intravenous) medication?

0. No

1. Yes

25. In the last three days, have you had any of the following problems?

a. been easilydistracted, had trouble paying attention,

or become sidetracked?

0. Behavior not present

1. Behavior present, consistent with usual functioning

2. Behavior present, new onset or worsening

b. threatened, cursed or screamed at others?

0. Behavior not present

1. Behavior present

Considerations:

  • The person becomes angry easily
  • Loses temper

c. wandered several times a day?*

0. Behavior not present

1. Behavior present

d. had hallucinations or delusions?*

0. Behavior not present

1. Behavior present

e. displayed any self-injurious behavior?*

0. Behavior not present

1. Behavior present

Code items #26, #27, #28 based on your conversation with the consumer; DO NOT ask the consumer directly. Ask as questions if interviewing a third party.

26. In the last three days, how well did the person made themselves understood?