Date of Birth: Surname: First Name: SLK

WA HACC ELIGIBILITY AND CLIENT ASSESSMENT FORM

Items marked with an * asterisk are mandatory fields required for entering data in the WAAFI.

CALLER/REFERRER DETAILS*Referrer/Caller First Given Name: *Referrer/Caller Surname/Family Name:

Referrer/Caller Contact Details:

Organisation: ____________________________Position: ________________________________*Phone Number: _______________________Fax Number: ____________________________Email Address: __________________________

Caller/Referrer Type:

(Not stated/inadequately described; Aboriginal Health Service; ACAT; Community Nursing or Health Services; Extended Care/Rehabilitation Facility; Family, significant other, friend; GP/Medical Practitioner community-based; Hospital; Health Professional; DSC; Self; Other; Other Community Based Service; Other Medical/health Facility; Psychiatric/mental health service or facility; Residential aged care facility; Law enforcement agency).

CLIENT DETAILS*Title:(Mr/Mrs/Ms/Miss/Dr/Fr/Br/Sr/Not stated)

*First Given Name:

Preferred Name: *Surname/Family Name:

*Date of Birth: *Date of Birth estimated: Yes No

*Gender: Male Female Medicare Number: IRN:

*Address: ________________________________________

Postal Address (if different from above):

________________________________________________________________________________

Contact Details:*Home Telephone Number: _____________________Work/Other Telephone Number _________________Mobile Telephone Number _____________________Email Address: ______________________________

*Main language spoken at home:

(Includes sign language; Makaton; Auslan)

Is an interpreter required?: Yes No Details:

*Country of Birth:

*Living Arrangement:Lives alone Lives with othersLives with family Not stated

*DVA Card Status:DVA Gold Card Other DVA CardDVA White Card

*Accommodation Setting:(Private residence – owned/purchasing; Private residence – private rental; Private residence – public rental; Independent living unit within a retirement village; Boarding house/private hotel; Short term crisis, emergency or transitional accommodation facility (includes Temporary shelter within an Aboriginal community); Supported accommodation or supported living facility (includes Domestic-scale supported living facility and Supported accommodation facility); Institutional setting; Public place/temporary shelter; Private residence rented from an Aboriginal Community; Other; Not stated/inadequately described)*Indigenous Status:Aboriginal but not Torres Strait IslanderOriginTorres Strait Islander but not AboriginalOriginBoth Aboriginal and Torres Strait IslanderOriginNeither Aboriginal nor Torres Strait Islander

*Pensioner Benefit Status:Age Pension Related BenefitVeterans’ Affairs (Pensions)Disability Support PensionUnemploymentCarer Payment (Pension)Other Government Pension BenefitNo Government Pension or Benefit

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OriginNot stated/inadequately describedAt time of screening for eligibility: If the client is not able to express their needs or client/carer is distressed refer direct to RAS at this point of interview.

WA HACC Eligibility Form not completed*Provide reason why:

For Regional Assessment ServiceReason assessment did not proceed: (Client/Carer declined; Redirection to more appropriate specialist services; Not HACC Eligible; Improved Circumstances; Other – provide comment)Comments:

CLIENT ELIGIBILITY QUESTIONS*Do you, or the person you care for, live in the community? Yes No This excludes Commonwealth funded residential care, Disability Services Commission and other funded group homes and mental health funded hostels*Do you, or the person you care for, have an ongoing functional disability which impacts on your/their ability to carry out day to day personal, household and social activities? Yes No Answering ‘yes’ to this question will make the functional screening questions(on page 3) mandatory in WAAFI.*Do you, or the person you care for, have a mental health condition (eg depression/anxiety) which impacts on your/their ability to carry out day to day personal, household and social activities?

Yes No

*If YES, are you receiving any support from a service provider/clinic? Yes No Unknown

*If YES, provide details if known.

*What difficulties are you currently experiencing that have led to your call?

How have you been managing until now?

If you don’t receive support will you be at risk of not being able to live in the community?

How long do you think you will need support?

Have you been discharged from hospital in the last three months? Yes No

If YES provide details:

*Are you or anyone in your house receiving any assistance from a service provider (e.g. household help, gardening, meals, transport or shopping)? Yes No

*Provide details

*Are you, or the person you care for, getting any other type of assistance (e.g. family, friends and/or carer)? Yes No

*If YES, provide details

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Are you interested in a short term (6-12 week) service that will support you to retain/regain your independence? Yes No

All Functional Screen fields below are mandatory.*Functional SCREEN Domestic and Self Care Functional Needs Identification

DOMESTIC & SELF CARE FUNCTIONS

Independent(manages without

help)3

Needs some assistance

(with some help)2

Dependent(completely unable

to manage)1

*Can you do your housework?*Can you get to places out of walking distance?*Can you walk (up to 20 metres)*Can you climb or descend stairs?*Can you go out shopping for groceries or clothes (assuming you have access to transport)?*Can you handle your own money?*Can you take your own medicine?*Can you prepare your own food?*Can you manage your eating?*Can you do your laundry (not including ironing)?*Do you ever need help to get out of bed, or move around at home (or places away from home)?*Can you take a bath or shower?*Can you dress yourself?*Can you manage your grooming?*Can you manage your bowels (faecal continence) and your bladder?*Can you manage your toilet use?*Do you ever need help to communicate?*Can you use the telephone?Totals Independence Needs Assistance Dependency

CARER SUPPORT Yes/Always3

Sometimes2

No/Never1

*Do you currently get regular help from a family member or an unpaid carer for domestic and/or self-care tasks?*If you currently get help from a family member or an unpaid carer is this help likely to be ongoing?

COGNITION AND BEHAVIOUR(do not ask the client)

NO = 0 Yes = 2

*Does the person have any memory problems or get confused?*Does the person have any behavioural problems?

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CARER SUPPLEMENT (CARER MDS SCREEN)No/Yes (If YES consider need for face to face assessment and/or referral to NRCP)

*Is there a carer?: Yes No *Does the carer live with the client? Co-resident Non-resident Not stated

*Relationship to client: (Spouse/partner; Parent; Son or daughter; Son-in-law or daughter-in-law; Other relative; Friend/neighbour; Not stated/inadequately described):

Title: (Mr/Mrs/Ms/Miss/Dr/Fr/Br/Sr)

*Carer’s First Given Name: *Carer’s Surname/Family Name:

Carer’s Preferred Name: *Carer’s Date of Birth:

*Carer’s Gender: Male Female *Carer’s Date of Birth estimated: Yes No

*Carer’s Address: __________________________ __________________________________ __________________________________ __________________________________ __________________________________

Carer’s Contact Details:Home Telephone Number: __________________Work/Other Telephone Number ______________Mobile Telephone Number __________________Email Address: ____________________________

Does the carer work? Yes No *If yes, Full Time Part Time

*Main language spoken at home by carer: Is an interpreter required: Yes No

*Country of Birth: Interpreter details:

*Indigenous Status:Aboriginal but not Torres Strait Islander Origin Neither Aboriginal nor Torres StraitTorres Strait Islander but not Aboriginal Origin Islander origin Both Aboriginal and Torres Strait Islander Origin Not stated/inadequately described

Does the carer need support?Yes No

*Carer provides assistance to more than one personYes No

IF CALLER IS THE CARER THE FOLLOWING QUESTIONS ARE TO BE COMPLETED

CARER NEEDS (ELIGIBILITY)If a care recipient is eligible to receive services funded under the HACC Program, then that person’s carer is eligible for HACC funded respite and counselling, support, information and advocacy services. However, if the identified carer is eligible for other HACC funded service types in his or her own right, a separate CNI should be completed for that person:Has another service provider completed a Carer Supplement for you? Yes No If YES seek further details, eg name of agency and contact details.

What difficulties are you currently experiencing that have led to your call?

How have you been managing until now?

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Carer’s SLK:

Date of Birth: Surname: First Name: SLK

EMERGENCY CONTACT DETAILS (IF DIFFERENT FROM CARER)*Do you have someone you would like us to contact in an emergency? Yes No If YES, provide details:Title: *Surname/Family Name:

*First Given Name: Relationship to client:

(Spouse/partner; Parent; Son or daughter; Son-in-law or daughter-in-law; Other relative; Friend/neighbour; Not stated/inadequately described)

Preferred Name:

Address: _______________________________

________________________________

________________________________

Contact Details:*Home Telephone Number: __________________Work/Other Telephone Number ________________Mobile Telephone Number ____________________Email Address: _____________________________

SECONDARY EMERGENCY CONTACT DETAILS (IF AVAILABLE)

Title: *Surname/Family Name:

*First Given Name: Relationship to client:(Drop down menu to select Family Member (Drop down menu to select Spouse/partner; Parent; Son or daughter; Son-in-law or daughter-in-law; Other relative; Friend/neighbour; Not stated/inadequately described):

Preferred Name:

Address: _______________________________ ________________________________ ________________________________ ________________________________ ________________________________

Contact Details:*Home Telephone Number: __________________Work/Other Telephone Number ________________Mobile Telephone Number ____________________Email Address: _____________________________

INFORMATION SHARINGRead the following statement to the potential client/carer:

It may be necessary to provide information about you to other individuals and agencies to ensure the most appropriate community care and support services can be provided to you and/or the person for whom you provide care. In addition, de-identified demographic and service provision information is routinely provided to the HACC Program for planning purposes. You can withdraw your consent to the sharing of your personal information at any time.

*Statement has been explained to the Client Yes No

*Statement has been explained to the Carer Yes No

*Variation made by client/carer Yes No *If YES provide details

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SCREENING PERSONNEL DETAILS

Screening Personnel Name(s): Eligibility Screen Date:

Organisation:

ELIGIBILITY SCREEN OUTCOME

Appears eligible and referred to:

Appears ineligible and reason:

Ineligible and referred for appeal to:

WA HACC ELIGIBILITY AND CLIENT ASSESSMENT FORM

*Face to face assessment Yes No *If NO reason why: _______________________________________________________________

Date Completed:

Assessment Reassessment Review

Recommended Review Date:

No Review required(Drop down menu to select: Client no longer needs assistance – improved status; Client only required one off service e.g. equipment, Home modifications; Client moved to residential care; Client moved to other community based service, e.g. Commonwealth Funded programs; Client terminated services; Client died; Other

CORE ASSESSMENT INFORMATIONCLIENT CURRENT STATUS

Is the client currently receiving any formal assistance from a Government funded program ( HACC or Non –HACC)

Yes No

*Provide details (mandatory when yes)

Self-reported health conditions

Impact of condition (ie fatigue, pain, reduced mobility, fear, balance issues, isolation, confusion, memory loss, disturbed sleeping patterns)

Are you happy to provide your GPs details?No Yes (provide details)

Name of GP: Name of Medical Centre/Practice:

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Address: _________________________________

__________________________________

__________________________________

Contact Details:Work/Other Telephone Number _______________Mobile Telephone Number ___________________Fax Number ____________________________Email Address: _____________________________

How satisfied is the client with their current level of independence?

1 2 3 4 5 Not at all Satisfied Very Satisfied

Comments:

CLIENT CURRENT STATUS - CONTINUEDIs a referral to a short term enablement program required? eg Home Independence Program (HIP)No Yes (provide details):

COMMUNICATION1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s abilities, difficulties and any support required. 2. Note any use of equipment which supports the client’s independence 3. If client is completely independent and does not use equipment/aids, ticking this box will close this section Independent in all areasVision Dependent (1)Some assistance (2)Independent (3)Hearing Dependent (1)Some assistance (2)Independent (3)Speech Dependent (1)Some assistance (2)Independent (3)

FUNCTIONAL ASSESSMENTMOBILITY, BALANCE AND TRANSFERS1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s abilities, difficulties and any support required. 2. Note any use of equipment which supports the client’s independence 3. If client is completely independent and does not use equipment/aids, ticking this box will close this section Independent in all areasMobility within homeDependent (1)Some assistance (2)Independent (3)

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Mobility outside of homeDependent (1)Some assistance (2)Independent (3)Transfers ie bed, chair, toilet and showerDependent (1)Some assistance (2)Independent (3)Using stepsDependent (1)Some assistance (2)Independent (3)

MOBILITY, BALANCE AND TRANSFERS - CONTINUEDEnvironmental AssessmentDoes the home environment have any barriers to the client’s independence?No Don’t Know Yes

If YES record further information and consider referral to appropriate service provider for home modifications as required. (See WA Assessment Framework – Suggested Referral Pathways for Equipment and Home Modifications for HACC Eligible Clients)

Modes of transport to access community (Drop down box: taxi; bus; drives self, other)

*Falls, stumbles or near misses inside/outside the home in the last three to six months No Yes :*Provide details:

If YES has the client attended a falls prevention program? No Yes Provide details:

If NO would the client consider attending a falls prevention program?

Provide details:

SELF CARE1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s abilities, difficulties and any support required. 2. Note any use of equipment which supports the client’s independence 3. If client is completely independent and does not use equipment/aids, ticking this box will close this section Independent in all areasBathing and showering Dependent (1)Some assistance (2)Independent (3)

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Dressing/undressing Dependent (1)Some assistance (2)Independent (3)GroomingDependent (1)Some assistance (2)Independent (3)Toileting Dependent (1)Some assistance (2)Independent (3)Continence 1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s abilities, difficulties and any support required. 2. Note any use of equipment which supports the client’s independence 3. If client is completely independent and does not use equipment/aids, ticking this box will close this section Independent in all areasFaecal ContinenceDependent (1)Some assistance (2)Independent (3)Urinary ContinenceDependent (1)Some assistance (2)Independent (3)Continence Aids / PadsDependent (1)Some assistance (2)Independent (3)Does the client have any other bowel or bladder problems (eg constipation, pain/difficulty in passing stool, increased need to urinate at night, abnormal bowel pattern, frequent diarrhoea or frequent urination?)No Yes

Provide details:____________________Has the client discussed their continence issues with anyone, eg GP/Continence Nurse Advisor?No Yes

Provide details:____________________Would the client like to discuss their continence issues with the Continence Management Advice Service? (CMAS)No Yes Provide details:____________________ Medication Management

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Dependent (1)Some assistance (2)Independent (3)

Describe medication management (e.g. packet, dossette, blister pack, other) Eating and DrinkingDependent (1)Some assistance (2)Independent (3)

Note any nutritional requirements

EVERYDAY ACTIVITIES1. If some assistance or dependency is noted DETAILS MUST BE PROVIDED of the client’s abilities, difficulties and any support required. 2. Note any use of equipment which supports the client’s independence 3. If client is completely independent and does not use equipment/aids, ticking this box will close this section Independent in all areasFood Preparation Cooking and/or preparing food/drinksDependent (1)Some assistance (2)Independent (3)Note any special dietary considerations/food allergiesShopping: eg groceries/clothesDependent (1)Some assistance (2)Independent (3)Housekeeping DutiesDependent (1)Some assistance (2)Independent (3)Household ManagementIncludes legal affairs, money management and/or bankingDependent (1)Some assistance (2)Independent (3)General Home Maintenance (including gardening)

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Dependent (1)Some assistance (2)Independent (3)

CARERS AND EQUIPMENTDoes the carer need to use equipment in their caring role? No Yes

Provide details:____________________

Is the carer confident in using the equipment? No Yes

Provide details:____________________

SOCIAL NETWORKS AND COMMUNITY ACTIVITIESDescribe the client’s current support networks and involvement in social and community activities (includes voluntary, employment, educational activities):

How satisfied is the client with their current involvement in social activities and interests?

1 2 3 4 5 Not at all Satisfied Very Satisfied

If the client identifies a low level of satisfaction continue with questions (a) and (b):

a) Identify if the client ever feels lonely and/or sad

b) Describe what the client would like to be able to do and what is currently preventing them from being involved?

PERSONAL STORY/SOCIAL HISTORYDetails of day to day routines, likes and dislikes, recent or significant life events, cultural and religious observances, occupations, hobbies and interests, sleeping patterns

Details of any information regarding the clients social situation that may need to be considered as part of recommendation for support

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Describe any cognitive or mental health problems (including depression, anxiety, behaviours of concern) identified that may need to be considered as part of the recommendations for support

Other relevant information

DESIRED OUTCOMES/REFERRALS WHERE IDENTIFIEDHas a referral for ACAT comprehensive assessment been made on behalf of the client?No Yes Provide details:______________________________________________

Has a referral to a specialist provider been made on behalf of the client?: (ie CAEP, Occupational Therapist, Physiotherapist, Podiatry, Continence Management and Advice Service)No Yes Provide details:__________________________________________________

DESIRED OUTCOMES/REFERRALS WHERE IDENTIFIED - CONTINUEDHas information been provided on how to access peak body support? (ie Association for the Blind, Alzheimer’s Australia WA, Neurocare, Carer’s WA, Advocare) No Yes Provide details:______________________________________________________

Has information been provided on how to access other agencies/community resources outside the HACC Program to support the client’s goals and independence? No Yes Provide details:____________________________________________________

Other referrals, outside of HACC support, made on behalf of the client:No Yes Provide details:__________________________________________________________

*Appropriate information has been provided to ensure client is informed of their rights and responsibilities and the complaints process.

No Yes

*If NO provide reason why:

Do you have someone who advocates for you or who is authorised to act on your behalf?No Yes (provide details)

Name: Relationship to client:(Drop down menu to select Advocate/Enduring Power of Attorney/Enduring Power of Guardianship)

ASSESSOR DETAILS

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Assessors Name(s): Date:

Regional Assessment Service Site: Contact Telephone Number:

Others Present at Assessment: No Yes If yes, name and relationship mandatory (enter details below).

*Name/s: *Relationship to client

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CAPACITY TO CONTRIBUTE HACC FEES FOR SUPPORT

Client has been provided with a copy of the WA HACC Standard Fees Schedule.Yes No

Client has been advised: They will be asked to pay a fee as a contribution towards the cost of the support that they

receive; The service provider(s) will discuss the fees to be charged when the support plan has

been finalised; If they are experiencing financial difficulty they may complete a Confidential Client Fee

Reduction Form and may have their fees reduced for a period; and No person will be refused HACC support based on their inability to pay fees.

Client has indicated they have the capacity to pay fees:

Yes No

Provide details:

OSH SCREEN - OBSERVATIONS

This is a summary of the Assessor’s initial observations at the time of assessment and is not intended to replace the service provider’s responsibilities under the Occupational Safety and

Health Act 1984. If a risk is observed, it is recommended that the SERVICE PROVIDER assess the risk further when they conduct their regular RISK ASSESSMENT.

To be used in conjunction with the Guidance Notes for WA HACC AssessmentOSH Screen not completed

*Provide details of reasons why (mandatory if box ticked):_______________________________________

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Access and Egress Nothing observed Risk identified Provide details_________________________________________________________________________

Chemicals Nothing observed Risk identified Provide details_________________________________________________________________________

Electrical Nothing observed Risk identified Provide details:_______________________________________________________________________

Emergency, Fire, Burns Nothing observed Risk identified Provide details: _______________________________________________________________________

Manual Tasks Nothing observed Risk identified Provide details:________________________________________________________________________

Oxygen Nothing observed Risk identified Provide details:________________________________________________________________________

Pets Nothing observed Risk identified Provide details:________________________________________________________________________

Pests Nothing observed Risk identified Provide details:________________________________________________________________________

Security Nothing observed Risk identified Provide details: _______________________________________________________________________

Slips, trips and falls Nothing observed Risk identified Provide details: _______________________________________________________________________

Smokers in the Home Nothing observed Risk identified Provide details: _______________________________________________________________________

Traffic Nothing observed Risk identified Provide details: ________________________________________________________________________

Violence and aggression Nothing observed Risk identified Provide details: _______________________________________________________________________

Other Nothing observed Risk identified Provide details: _______________________________________________________________________

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