Microsoft word - sampleassessmentjohnsmith

Assessment and Evaluation
Client Number and Name: #1221 John Smith*
Assessment Date:
February 5
Assessed By:
Sue, Aging Wisely Care Manager


Current Living Arrangement: Own home
Phone: (727)555-5555
Address: 275 West Dr., Clearwater, FL 33761

DOB: 2/1/29
Social Security #: 222-22-1111
Marital Status: Widow
US Citizen: Yes
Veteran: Yes, Army
Religious Preference: Methodist
Church Affiliation:

Emergency Contacts:
Pam, daughter
Home Phone: (813)-555-5555
Cell Phone: (813)222-2222
2. Jan, daughter
Home Phone: (813)444-4444
Work Phone: (888)900-9000
3. Bob, son
Home Phone: (888)888-8888

Medical Information

Primary Physician: Stanley Moore, Cardiologist Phone: (727)777-0000
2000 West Bay Dr., Largo, 33770

Secondary Physician: Dr. Anthony Stephens, Psychiatrist
1000 County Rd. 1, Dunedin
Phone: (727)888-0000

Secondary Physician: Dr. John Smits, Urologist
500 Jeffords St., Clearwater
Phone: (727)-999-0000

Coronary Artery Disease

Medical History (including previous surgeries): Redo coronary artery bypass February 1993,
left internal carotid endarterectomy July 1996, right internal carotid endarterectomy November
1180 Ponce de Leon Blvd., Suite 701 • Clearwater, Florida 33757 • Phone 727-447-5845 • Fax 727-461-0001 • Toll Free 1-888-807-2551 1996, bladder cancer early 1980s, cataracts removed in both eyes, right eye lens replacement,
sternum removed

Allergies: Penicillin


1) Pravachol, 40mg
2) Buspar, 15mg
1/2 tab in a.m., 1/2 tab at bedtime, 1/3 tab during the day 3) Norvasc, 10mg
4) Aspirin, 81mg
5) Prostata
6) Restoril, 30mg
7) Seconal, 100mg

Legal Information

Family reports all documents up to date. Health Care Surrogate: Yes, Janet
Copy of Document on File: No
Living Will:
Copy of Document on File: No
Durable Power of Attorney: Yes, Janet, Rich, & Karen Copy of Document on File: No
Do Not Resuscitate Order:
Copy of Document on File: No
Estate Plan (Will/Trust): Will completed.
Copy of Document on File: No

Attorney: John Van Eli
Phone: (727)444-0000
Address: 1000 Gulf to Bay Blvd.
Burial Arrangements

Plot Location: West Gardens
Prepaid Arrangements:
yes, funeral prepaid and daughter Pam has all information

Social History

Past relationships, occupations, interests: Mr. Smith was married 57 years to Genie a retired
registered nurse. He worked for General Motors for 25 years, rising to the title of VP of Sales.
He was forced to retire early due to his health and moved to Florida to "get away from the
automobile industry". He and Genie raised 7 children. Three of the children reside in the
community; the others are in various states.

Past: golf, stocks, train set, church
Present: stocks
Self Esteem: Appears intact
Recent Stress:
Wife's death
Grieving Behavior:
Episodes of crying
Good, episodes of judgement being compromised
Appears intact
Relationships with Family:

1180 Ponce de Leon Blvd., Suite 701 • Clearwater, Florida 33757 • Phone 727-447-5845 • Fax 727-461-0001 • Toll Free 1-888-807-2551 Cognitive Abilities

Oriented (Person, Place, & Time): Oriented times three
Appears appropriate
No symptoms noted
History of anxiety attacks
Potential for depressive mood


Short Term: Family notes some episodes of compromised short-term memory
Long Term:
Appears intact

Activities of Daily Living

Total Assist
Meal Preparation:
Mr. Smith will warm up prepared meals for himself but does not cook.

Special Diet: N/A
According to Mr. Smith he is gradually losing weight.
Home Environment/Safety Issues

Stairs: Yes, according to Mr. Smith he climbs the stairs approximately one time per week.
Emergency Response System: Yes Provider: Lifeline Phone: (800) 635-6156
Scatter Rugs: Bathroom
Grab Bars in Bathroom:
Other Areas: N/A
Smoke Alarm: Yes
Telephone Next to Bed:
Outdated Medicines:
None noted
Emergency Numbers Posted:
No list observed
Hurricane Supplies & Evacuation Plan:
Family will assist during an evacuation

Presenting Problems/Issues

Identified by Client: Mr. Smith reports he wants to continue residing in his home. He further
stated he wants to "give it a try" residing independently with some assistance and support.
Identified by Family: In speaking with the family, all the siblings seem to generally agree about
several main concerns about their father. First, they want to ensure that he is safe in the home,
particularly as they have some concerns about his steadiness on his feet and some short-term
1180 Ponce de Leon Blvd., Suite 701 • Clearwater, Florida 33757 • Phone 727-447-5845 • Fax 727-461-0001 • Toll Free 1-888-807-2551 memory issues. They are concerned about the pool in particular, as Dad has fallen into the pool
and injured himself before. Additionally, the children noted some concerns about their father’s
driving, although they have taken safety precautions so that he does not drive at night or in high
traffic areas. Night driving and driving out of his local neighborhood are the biggest concerns
and there are some additional concerns about possibly becoming lost. One of the other key
issues is that their father does not feel safe alone at night. He has had this fear for many years,
since developing his heart condition. They feel it is presently important to him to have the
security of a caregiver at night, simply to be there in case he needs someone.
Second, they are concerned about their father’s general daily pattern and the changes he is
facing. Their mother was his 24-hour companion and primary contact for many years. Their
concerns in this area appear to be twofold. First are daily tasks, such as preparing meals and
tending to the household. Second, are Dad’s social needs and potential for depression. The
siblings all noted the importance of their father having stimulation and activities. They also
noted that he is a very social person who enjoys conversation, but
may be reluctant to instigate relationships. He has been very involved in his church, but that had
decreased over the past couple years due to some changes in the church leadership and Mrs.
Smith’s declining health.
The siblings would like their father to investigate alternate living situations. However, they do
acknowledge that their father is somewhat hesitant about a move and that there are grief issues to
deal with at present. They are amenable to considering this as a future option when their father
becomes ready to consider it.
Identified by Care Manager: There are a number of immediate concerns although this is a
difficult time to assess Mr. Smith's needs due to the recent loss of his wife. Currently, the
siblings have been alternating caregiving responsibilities, staying with their father, and helping
with the upkeep of the house and day-to-day concerns, as well as spending nights with him. They
acknowledge that it is important to be cognizant of their own familial duties and responsibilities.
On-going care provided by family members could pose issues related to caregiver burnout,
fostering Mr. Smith's dependency on others, sibling rivalry, and harm to personal relationships.
Without a fulltime caregiver, Mr. Smith's safety becomes a concern. Although we applaud Mr.
Smith's use of his lifeline, there are numerous safety issues to address. Finally, it will be
extremely important to slowly build Mr. Smith a social support system in addition to his family.

Recommendations/Plan of Action
In preparing this assessment a few important factors continue to emerge. First, Mr. Smith and
the Smith family have been through a very difficult month with the loss of their wife/Mother.
The plan must be viewed as a work in progress, as Mr. Smith continues to adjust, changes will
need to be made to the plan. Second, although family member's willingness and commitment to
care for their father is commendable it cannot continue indefinitely. We applaud the support and
care provided by family members but must recognize each has their own families and
responsibilities to consider. It is also important that adult children be able to enjoy their role as
"child", allowing professionals to provide specific services. Third, the need for a routine is
essential. Most individuals thrive on stability and routine. It will take everyone involved to help
develop a comfortable, beneficial routine for Mr. Smith. With the support of his family and
some professional assistance, Mr. Smith should flourish in any environment.
1180 Ponce de Leon Blvd., Suite 701 • Clearwater, Florida 33757 • Phone 727-447-5845 • Fax 727-461-0001 • Toll Free 1-888-807-2551 1. Recommend Mr. Smith have a home health aide with him 18 hours per day, from 3:30pm to 9:30am. The home health aide would be responsible for several tasks including but not limited to: • Meal preparation • Supervising consumption of medications • Household laundry/ironing • Light housekeeping (i.e. vacuuming, dusting, kitchen clean up, etc.) • Transportation as Mr. Smith needs • Transportation and accompaniment to grocery store and other errands • Transportation to outings as Mr. Smith instructs • Transportation to physician appointments (transportation needs between 9:30am and 3:30pm can be arranged in advance with home health aide, a family member may be able to assist, or a contract with a cab company can be established)
Suggested Providers:
Bay Home Health
Contact Person: Mary
Phone: (727)777-7777
$16.25/hour (any time, only changes for major holidays)
use one caregiver for 1st shift and another for second, different person on the weekends; strive for
good match and consistency.
18 hours x $16.25/hour = $292.50/day x 30 days = $8775. per month
24 hours x $16.25/hour = $390.00/day x 30 days = $11700. per month
Coast Health
Contact Person: Catherine Phone: (727)888-8888
$12.50/hour for companion (can do light housekeeping, meals, etc.)
$14.50/hour for CNA (Certified Nursing Asst.)
18 hours x $12.50/hour = $225.00/day x 30 days = $6750. per month
24 hours x $12.50/hour = $300.00/day x 30 days = $9000. per month

Other options:
Live-in: $125/day x 30 days = $3750.00/month + food/groceries
less expensive, would be able to do all housekeeping, assist with driving, appointments,
Cons: finding good match very difficult, one person can have undue influence on the client thus
we always recommend at least 2 caregivers working within one household.
Additional Notes: Recommend considering decreasing Dolores to one time per week. We
recognize the long-standing relationship but must note the home health aide can complete
ironing quietly during the night while Mr. Smith sleeps. Also prices for a "home health aide"
and a "companion" were provided. A home health aide can assist with hands-on, personal care
such as bathing, dressing, etc. Although these services are not currently needed, it is often a
good idea to build a relationship with someone that could be involved long term. A companion
cannot provide hands on care.
2. Recommend Mr. Smith and his family investigates alternative living opportunities.
Specifically recommend touring the following communities: 1180 Ponce de Leon Blvd., Suite 701 • Clearwater, Florida 33757 • Phone 727-447-5845 • Fax 727-461-0001 • Toll Free 1-888-807-2551 Notes: new community, independent living only, price range: $1650 - $2800 1900 East Lake Rd., Palm Harbor, 34684 Notes: independent & assisted living, price range: $2200 - $4300 2000 Tampa Rd., Palm Harbor, 34684 Notes: assisted living only, AW has several clients residing their who are happy with services and staff, price range: $2575 - $4000 300 Seminole Blvd., Largo, 33771 Notes: independent & assisted living, price range: $2060 - $4000 Note: Care managers have been successful at negotiating lower rent fees with communities. 3. Recommend the completion of a weekly calendar that will address Mr. Smith's social, emotional, spiritual, intellectual, and physical wellbeing. The calendar should be posted in an accessible place for all to view. Suggested activities/outings include, but are not limited to: • Dunedin Senior Center (see attached) • Hospice General Bereavement Support Group, Phone: 588-2812, Palm Harbor office (corner of Tampa Rd. & West Lake Rd.), next group begins March 20th, each Thursday from 10:00am to 12:00pm for 6 weeks. Call Hospice to register. • Church Men's group (see attached) • Bridge group • Dinner outings with friends • Dining Centers (see attached), transportation is provided • Daily walks/exercise- informal & formal (see attached) 4. There are several recommendations regarding safety concerns. They are as follows: • Pour medications into a weekly "medication planner". This allows for accurate consumption of medications. Also utilize website to provide monthly medication charts, wallets size list of medications, etc. (see attached). • Remove scatter rugs in the bathroom, they pose a fall risk. • Install a pool fence. It was reported Mr. Smith had fallen into/around the pool on several occasions. A pool fence would help decrease the risk of accident. • Post reminder notes throughout the house. For example, post a note on the screen door • Complete the information for the Vial of Life program (see attached). This is a program that alerts emergency medical professionals who come to your door where to find important medical information. • Program all children's numbers into Mr. Smith's cell phone. He should be instructed on how to use it and encouraged to take it everywhere he goes. • Discourage use of the stairs by roping them off and bringing down any items Mr. Smith may need and attempt to retrieve. Remove or secure all ladders and step stools to remove/discourage their use. 1180 Ponce de Leon Blvd., Suite 701 • Clearwater, Florida 33757 • Phone 727-447-5845 • Fax 727-461-0001 • Toll Free 1-888-807-2551 • Complete attached Check Your Own (Driving) Performance pamphlet attached. Complete the AARP “55 Alive Course”, contact AARP for class schedule at 571-2277. 5. Recommend care manager continue to assist Mr. Smith with the development of a comfortable weekly routine, securing appropriate home health aides, touring alternative living communities, and securing his home. Care manager also recommends routine visits to monitor Mr. Smith's progress towards goals and provide proactive recommendations as need arise. 6. Recommend a Health File be created for Mr. Smith (see attached). A Health File provides accessible, important medical information when needed and allows a system for keeping medical information accurate and up to date. Care manager can set up a Caregiver’s Touch account for the client and assist the family in creating a personal, online record that will be useful for the client and family caregivers.
Liz Barlowe, MA, CMC
Shannon Martin, MSW, CMC

*names of individuals and facilities have been changed
1180 Ponce de Leon Blvd., Suite 701 • Clearwater, Florida 33757 • Phone 727-447-5845 • Fax 727-461-0001 • Toll Free 1-888-807-2551



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