Free VA Form 10-0415 - VA Geriatrics and Extended Care (GEC) Referral - fillable - Federal

VA Geriatrics and Extended Care (GEC) Referral
1. Source of Referral This referral is being made from? (Check one)
1.1 Outpatient Clinic 1.2 Hospital < 7 days 1.3 Hospital > 6 days 1.4 VA Nursing Home 1.5 Community Nursing Home 1.6 VA Domiciliary 1.7 HBPC 1.8 Other (Specify)

2. Living Situation 2.1 With whom does the patient live? (Check one)
2.1.1 Alone 2.1.2 Spouse only 2.1.3 Spouse with others 2.1.4 Child (not spouse) 2.1.5 Others (not spouse or children) 2.1.6 Group setting with non-relatives 2.1.7 Other (Specify)

2.2 Where does the patient live? (Check one)
2.2.1 Private home/Apartment 2.2.2 Board and Care/Assisted Living 2.2.3 Nursing Home 2.2.4 Domiciliary 2.2.5 Homeless 2.2.6 Homeless shelter 2.2.7 Other (Specify)

3. Primary Caregiver Information
Primary (unpaid) Caregiver The person (unpaid) who provides most support for patient, need not be a relative. Do NOT include any paid caregivers here 3.1 No caregiver Check no caregiver only if there is no one on whom the patient relies on for any type of support. Do not check if there is ANY person who provides ANY type of support 3.2 Last name 3.4 Street Address 3.3 First name

6. Instrumental Activities of Daily Living In the last 7 days, has the patient expressed difficulty with the following activities? Last 7 Days YES NO

Consider how difficult it is or would have been for the patient to perform these IADL activities on his/her own in the last seven days. If you have not seen the patient perform these tasks, you must use your judgment. 6.1 Preparing Meals (planning, cooking, setting out food and utensils) Answer YES if patient does NOT prepare meals, even if s/he could.

3.5 City 3.8 Telephone number with area code

3.6 State

3.7 ZIP

6.1.1 Were meals prepared by others? 6.2 Housework (e.g., dishes, dusting, laundry) 6.3 Shopping (selecting items, managing money) 6.4 Transportation (getting to places beyond walking distance-any mode) 6.5 Using the phone (receiving or making calls - may use assistive devices) 6.6 Managing medications (remembering to take meds, refill meds, opening bottles, correct dosages, etc) 6.7 Managing own finances (maintaining a checkbook, paying own routine bills, etc.) 6.8 Do any of the answers above (6.1 - 6.7) indicate recent (e.g., 2-3 mo) change in functioning? Code NO if patient has been in hospital, nursing home or out of the home for the time period of the question. 7.1 In the last 14 days, has the patient received assistance from a home health aide in the home? 7.2 In the last 14 days, has the patient received assistance from a social worker in the home? 7.3 In the last 30 days has the patient received help in the home from an RN? OR is an RN scheduled or authorized to make home visits in the next 30 days?

3.9 Caregiver's relationship to patient? (Check one) Spouse Child or child-in-law Other relative Friend/neighbor

3.10 Support provided by informal caregiver (Check all that apply) Advice/emotional support ADL help IADL help YES YES NO NO

3.11 Caregiver lives with patient? 3.12 Caregiver accessible to patient? Lives close enough to see pt. and provide care regularly. 3.13 Caregiver willing/able to increase help? Ask caregiver if s/he is willing, use your own judgment about his/her ability to increase help. Code NO if the caregiver is unwilling or, if in your judgment, is unable.

7. Services in the Home

YES NO

YES

NO

4. Language (Check any language the patient speaks and understands)
4.1 English Spanish Other (specify)

5. Homebound Status
5.1 Is the patient homebound (able to leave the home only infrequently and for short periods of time)? YES NO

PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL

SOCIAL SECURITY NO. VA FORM MAY 2006

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8. Additional Information
8.1 In the last 90 days, has the patient moved in with others or have others moved in with the patient? 8.2 Are there any hazards or other factors that make it difficult for the patient to enter or leave the home? Any environmental factor e.g., environmental factors such as stairs, broken elevators, etc., that make it difficult to leave the home (do not count poor lighting or loose rugs/carpet) 8.3 Does the patient or primary caregiver believe the patient would be better off in another living environment? 8.4 In the last 7 days, did the patient engage in 2 or more hours of physical activity, e.g., walking, cleaning the house or exercising? 8.5 In the last 7 days, has the patient been left alone in the mornings or afternoons? YES, Performed for 2 or more hours NO, not performed or less than 2 hours YES, Occasionally alone, even if only for an hour NO, Never or hardly ever

YES NO

8.6 Does the veteran have a substitute (surrogate) decision-maker designated? (Check any that apply, include names when available) Guardian Fiduciary/Conservator 8.7 Has the patient completed an Advance Directive? YES NO Durable Power of Attorney Health Care Financial (If yes, please place copy in Medical Record or send with patient)

9. Skilled Care
Will the patient require these treatments after referral? 9.1 CPAP/BiPap or Ventilator 9.2 Oxygen 9.3 Suctioning 9.4 Tracheostomy Care 9.5 Ostomy Care (other than tracheostomy) 9.6 Dysphagia Diet 9.7 Tube Feeding (any method) 9.8 Parenteral Feeding 9.9 IV Infusions 9.10 Medications by Injection 9.11 Urinary Catheter Care 9.12 Dialysis - Center- based 9.13 Dialysis - Home -based 9.14 Wound Care (other than pressure ulcer) 9.15 Pressure Ulcer Care 9.16 1 Check the stage of the worst pressure ulcer 2 3 4

YES

10. Basic Activities of Daily Living Code YES if the patient had ANY difficulty, required cueing or supervision, or DID NOT do the task in the last 7 days Last 7 In the last 7 days, has the patient required help OR supervision to Days
perform any of the following activities?

YES NO

10.1 Bathing (tub bath, shower, or sponge) 10.1.1 Did the patient require physical assistance with bathing? 10.2 Dressing (lower and upper body) 10.3 Eating (taking in food by any method, including tube feedings) 10.4 Using the toilet (using toilet, urinal, bedpan-getting on and off, cleaning self, managing devices used and adjusting clothes) 10.5 Moving around in bed (moving to and from lying position, turning side to side, repositioning) 10.6 Transfers (moving to/from bed, chair, wheelchair, standing) 10.7 Moving around indoors (Answer yes even if with cane, walker, or scooter - Answer NO if uses wheelchair OR did not get around 10.8 If uses wheelchair, moving around chair (propelling and maneuvering) Code YES if the patient can maneuver wheelchair by him/herself (even if it is a power chair) 10.9 Do any of the answers above (10-1 - 10-7) indicate a recent (2-3 mos) change in functioning? Code yes if the patient's function has significantly changed in the recent past YES NO

11. CONTINENCE
11.1 Is the patient incontinent of urine? 11.2 Is the patient incontinent of stool?

YES NO

9.17 Frequent Nurse Observation (more than 1/week) 9.18 Physical, Speech, Occupational or Kinesiotherapy 9.19 Alcohol, Drug, or other substance abuse treatment 9.20 Other (specify)

12. SKIN
12.1 Has the patient experienced any troubling skin problems like burns, bruises, or itching in the last 30 days? Additional comments pertinent to this page have been added

YES NO

PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL VA FORM MAY 2006

SOCIAL SECURITY NO.

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13. Patient Behaviors and Symptoms
In the last 7 days, has the patient exhibited any of the following?

Last 7 Days YES NO

I3.1 Wandering (moved with no rational purpose, seemingly oblivious to needs or safety)? Wandering is purposeless movement often without regard to safety. Pacing up and down is NOT wandering. I3.2 Verbally abusive behaviors (threatened, screamed at, or cursed at others)? Code if any such behavior occurred, regardless of patient's intent. I3.3 Physically abusive behaviors (hit, shoved, scratched or sexually abused others)? Code if any such behavior occurred, regardless of patient's intent. I3.4 Resisting care (resisted taking medications /injections, ADL assistance, eating, or changes in position)? I3.5 Hallucinations or delusions? Hallucinations are sensory (auditory, visual, olfactory, tactile) experiences that are NOT real Delusions are ideas or beliefs that are held even though there is no evidence to support them or evidence that shows them to be false.

14. Cognitive Status
14.1 In the last 7 days was the patient able, without difficulty, to make decisions that are reasonable about organizing the day, such as when to get up, what meals to have or what clothes to wear? I4.2 In the last 7 days, has the patient usually been able to make him/herself understood? YES, Patient consistently made reasonable decisions without difficulty NO, Patient made decisions with difficulty OR did not make decisions OR decisions were poor YES, Patient's expression of information is understood, even if s/he has difficulty in finding words or finishing thoughts NO, Patient's expression of information is never (or rarely) understood OR s/he is limited to making concrete requests YES NO

I4.3 In the last 90 days has the person become so agitated or disoriented that his safety was endangered or s/he required protection by others as a result?

15. Prognosis
I5.1 In the last 7 days, has the person experienced a flare up of a recurrent or chronic health problem? I5.2 Does the direct care staff (MD, rehab therapist) think the patient is capable of increased independence (in ADLs, IADLs, or mobility)? I5.3 Does the patient have a limited life expectancy (likely to be less than 6 months)? YES YES YES NO NO NO

16. Weight Bearing
I6.1 What is the patient's weight bearing status? Full Partial None

17. Diet
I7.1 Diet Regular Modified (Specify diet)

18. What equipment does the patient need? (Please place prosthetics requests)
18.1 Hospital Bed 18.2 Special mattress 18.3 Trapeze 18.4 Walker 18.5 Cane 18.6 Wheelchair 18.7 ADL equipment 18.8 Orthotic or splint 18.9 Other (specify)

19. What supplies does the patient need? (Please place orders for supplies)
19.1 Catheters 19.2 Tubing 19.3 Dressings 19.4 Wrappings 19.5 Tape 19.6 Glucose strips 19.7 Ostomy supplies 19.8 Saline SOCIAL SECURITY NO. 19.9 Other (specify)

PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL

VA FORM MAY 2006

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VA Geriatrics and Extended Care (GEC) Referral con't
20. Goals of Care (check all that apply)
20.1 Rehabilitation (improved function) 20.2 Skilled nursing care (e.g., manage wounds, medical devices, catheters, ostomy) 20.3 Monitoring/supervision to avoid clinical complications 20.4 Improve compliance with medications/treatments 20.5 Patient/Family Education 20.6 Respite (temporary relief for caregiver) 20.7 Palliative/End of Life Care 20.8 Reduce hospitalizations and/or ER visits 20.9 Supervised/supportive living situation 20.10 Behavior Stabilization

21. Referring to which program? (Check all that apply)
21.1 Skilled care in home 21.2 Home Based Primary Care (HBPC) 21.3 ADL assistance (personal care) in home 21.4 Chore Services (homemaker) in home 21.5 Adult Day Health Care 210.6 Residential care (supervised living) 21.7 Assisted Living 21.8 Domiciliary care 21.9 Short-term nursing home care (subacute care, rehab, etc) 21.10 Long-term nursing home care 21.11 Outpatient Respite care 21.12 Inpatient Respite care

21.13 Specialized Dementia or Geropsych Care 21.14 Inpatient palliative/hospice care (in NHCU ) 21.15 Outpatient Palliative/ hospice care (in home) 21.16 All inclusive care or PACE program 21.17 Other (specify)

22. Estimated Duration of Care
22.1 1 week 22.2 2-3 weeks 22.3 One month 22.4 2-3 months 22.5 4-6 months 22.6 Indefinite Comments. (Any additional information that may be helpful to the referral program)

PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL

SOCIAL SECURITY NO.

VA FORM MAY 2006

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This Section for Administrative Use Only

Use This Section Referral is processing (Check all that apply)

23. Where was the patient referred? Home Care
Community Skilled Home Health Care VA Home-Based Primary Care Homemaker/Home Health Aide VA Bowel and Bladder Adult Day Health Care VA In-home Respite

Funding Sources for Funding Sources for Structured Living Situation Structured Living Situation Home Care
VA Medicare Medicaid Other insurance Private Pay Other (specify) Personal Care Home Community Residential Care Assisted Living VA Medicare Medicaid Other insurance Private Pay Other (specify)

Domiciliary
VA Domiciliary State Home Domiciliary

Funding Sources for Domiciliary
VA Medicare Medicaid Other insurance Private Pay Other (specify)

Nursing Home Care
VA NHCU (Rehab) VA NHCU (Long-term care) VA NHCU (subacute care) VA NHCU (respite) Community nursing home State Veterans nursing home VA NHCU (Hospice) VA

Funding Sources for Nursing Home Care
Medicare Medicaid Other insurance Private Pay Other (specify)

Hospice Care
VA NHCU (Hospice) VA Outpatient hospice Community hospice

Funding Sources for Hospice Care
VA Medicare Medicaid Other insurance Private Pay Other (specify)

Geriatric Services
GEM Clinic Geriatric Primary Care Clinics VA GEM inpatient unit VA

Funding Sources for Geriatric Services
Medicare Medicaid Other insurance Private Pay Other (specify)

Care Coordination/Home Telehealth
Care Coordination/Home Telehealth

Funding Sources for Care Coordination/Home Telehealth
VA Medicare Medicaid Other insurance Private Pay Other (specify)

OTHER (specify)
VA

Funding Sources for OtherServices

Medicare Medicaid Other insurance Private Pay Other (specify)

PATIENT'S LAST NAME, FIRST NAME, MIDDLE INTIAL VA FORM MAY 2006

SOCIAL SECURITY NO.

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