<table style="width:100%;">
<colgroup>
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 17%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 21%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="34"><p
id="va-geriatrics-and-extended-care-gec-referral-8-22-05"
class="heading">VA Geriatrics and Extended Care (GEC) Referral
(8-22-05)</p></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="8"><strong>1. Source of Referral</strong></td>
<td colspan="26"><strong>2. Living Situation</strong></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>This referral is being made from?<br />
<em>(Check one)</em></strong></td>
<td colspan="10"><strong>2.1 With whom does the patient live?<br />
<em>(Check one)</em></strong></td>
<td colspan="16"><strong>2.2 Where does the patient live?<br />
<em>(Check one)</em></strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4">1.1 Outpatient Clinic</td>
<td colspan="4"></td>
<td colspan="9">2.1.1 Alone</td>
<td></td>
<td colspan="9">2.2.1 Private home/apt</td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4">1.2 Hospital &lt; 7 days</td>
<td colspan="4"></td>
<td colspan="9">2.1.2 Spouse only</td>
<td></td>
<td colspan="9">2.2.2 Board and Care/Assisted Living</td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4">1.3 Hospital &gt; 6 days</td>
<td colspan="4"></td>
<td colspan="9">2.1.3 Spouse with others</td>
<td></td>
<td colspan="9">2.2.3 Nursing Home</td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4">1.4 VA Nursing Home</td>
<td colspan="4"></td>
<td colspan="9">2.1.4 Child (not spouse)</td>
<td></td>
<td colspan="9">2.2.4 Domiciliary</td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4">1.5 Community Nursing Home</td>
<td colspan="4"></td>
<td colspan="9">2.1.5 Others (not spouse or children)</td>
<td></td>
<td colspan="9">2.2.5 Homeless</td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4">1.6 VA Domiciliary</td>
<td colspan="4"></td>
<td colspan="9">2.1.6 Group setting with non-relatives</td>
<td></td>
<td colspan="9">2.2.6 Homeless shelter</td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4">1.7 HBPC</td>
<td colspan="4"></td>
<td colspan="9" rowspan="2">2.1.7 Other (Specify)</td>
<td colspan="2" rowspan="2"></td>
<td colspan="10" rowspan="2">2.2.7 Other (Specify)</td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="4">1.8 Other (Specify)</td>
<td colspan="4"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="13"><h1 id="primary-caregiver-information">3. Primary
Caregiver Information</h1></td>
<td colspan="21"><h1 id="instrumental-activities-of-daily-living">6.
Instrumental Activities of Daily Living</h1></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="5"><p><strong>Primary (unpaid)</strong></p>
<p><strong>Caregiver</strong></p>
<p>The person (unpaid) who provides most support for patient, need not
be a relative. Do NOT include any paid caregivers here</p></td>
<td colspan="12"><p>3.1 No caregiver</p>
<p>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</p></td>
<td colspan="8" rowspan="2"><p>In the last 7 days, has the patient
expressed <strong>difficulty</strong> with the following activities?</p>
<p><em>Consider how <strong>difficult</strong> it <strong>is</strong> or
<strong>would have been</strong> for the patient to perform these IADL
activities on his/her own in the last seven days. <strong>If you have
not seen the patient perform these tasks, you must use your
judgment.</strong></em></p></td>
<td colspan="13"><h1 id="last-7-days">Last 7 Days</h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2">3.2 Last name,</td>
<td colspan="7" rowspan="2">3.3 First name</td>
<td colspan="6"><strong>Yes</strong></td>
<td colspan="7"><strong>No</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8">6.1 Preparing Meals (planning, cooking, setting out food
and utensils) <em>Answer yes if patient does NOT prepare meals, even if
s/he could.</em></td>
<td colspan="6"></td>
<td colspan="7"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="12" rowspan="2">3.4 Street Address</td>
<td colspan="8">6.1.1 Were meals prepared by others?</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8">6.2 Housework (e.g., dishes, dusting, laundry)</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="12"></td>
<td colspan="9">6.3 Shopping (selecting items, managing money)</td>
<td colspan="6"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5">3.5 City</td>
<td colspan="3">3.6 State</td>
<td colspan="4">3.7 ZIP</td>
<td colspan="8">6.4 Transportation (getting to places beyond walking
distance–any mode)</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13">3.8 Telephone number ( ) -</td>
<td colspan="8">6.5 Using the phone (receiving or making calls – may use
assistive devices)</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="13"><p>3.9 Caregiver’s relationship to patient? (Check
one)</p>
<p> Spouse Child or child-in-law</p>
<p> Other relative Friend/neighbor</p></td>
<td colspan="8">6.6 Managing medications (remembering to take meds,
refill meds, opening bottles, correct dosages, etc)</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="12"><p>3.10 Support provided by informal caregiver (Check
all that apply)</p>
<p> Advice/emotional support ADL help IADL help</p></td>
<td colspan="8">6.7 Managing own finances (maintaining a checkbook,
paying own routine bills, etc.)</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11">3.11 Caregiver lives with patient?</td>
<td colspan="2">Yes No</td>
<td colspan="8">6.8 Do any of the answers above (a-g) indicate recent
(e.g., 2-3 mo) change in functioning?</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="11"><ol start="12" type="1">
<li><p>Caregiver accessible to patient?</p></li>
</ol>
<p>Lives close enough to see pt. and provide care regularly.</p></td>
<td colspan="2">Yes No</td>
<td colspan="8"><p id="services-in-the-home" class="heading">Services in
the Home</p>
<p><em>Code NO if patient has been in hospital, nursing home or out of
the home for the time period of the question</em>.</p></td>
<td colspan="6"><strong>Yes</strong></td>
<td colspan="7"><strong>No</strong></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11"><ol start="13" type="1">
<li><p>Caregiver willing/able to increase help?</p></li>
</ol>
<p>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.</p></td>
<td colspan="2">Yes No</td>
<td colspan="8">7.1 In the last 14 days, has the patient received
assistance from a home health aide in the home?</td>
<td colspan="6"></td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="15"><h1
id="language-check-any-language-the-patient-speaks-and-understands">4.
Language (Check any language the patient speaks and
understands)</h1></td>
<td colspan="8" rowspan="2">7.2 In the last 14 days, has the patient
received assistance from a social worker in the home?</td>
<td colspan="8" rowspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="15">4.1 English Spanish Other (specify)</td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="15"><h1 id="homebound-status">5. Homebound Status</h1></td>
<td colspan="8" rowspan="2">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?</td>
<td colspan="8" rowspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="10">5.1 Is the patient homebound (able to leave the home
only infrequently and for short periods of time)?</td>
<td colspan="5">Yes No</td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="21"><h1 id="additional-information">8. Additional
Information</h1></td>
<td colspan="6"><h1 id="yes">Yes</h1></td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="21">8.1 In the last <strong><u>90</u></strong> days, has
the patient moved in with others or have others moved in with the
patient?</td>
<td colspan="4"></td>
<td colspan="9"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="21"><ol start="2" type="1">
<li><p>Are there any hazards or other factors that make it difficult for
the patient to enter or leave the home?</p></li>
</ol>
<p>Any environmental factor e.g., stairs, broken elevators, etc that
make difficult to leave the home (do not count poor lighting or
carpet)</p></td>
<td colspan="4"></td>
<td colspan="9"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="21">8.3 Does the patient or primary caregiver believe the
patient would be better off in another living environment?</td>
<td colspan="4"></td>
<td colspan="9"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="18">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?</td>
<td colspan="16"><p> <strong>YES,</strong> Performed for
<strong><u>2</u></strong> or more hours</p>
<p> <strong>NO</strong>, not performed or less than
<strong><u>2</u></strong> hours</p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="18">8.5 In the last 7 days, has the patient been left alone
in the mornings or afternoons?</td>
<td colspan="16"><p> <strong>YES,</strong> Occasionally alone, if even
for an hour</p>
<p> <strong>NO,</strong> Never or hardly ever</p></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="32"><ol start="6" type="1">
<li><p>Does the veteran have a substitute (surrogate) decision maker
designated? (Check any that apply, include names when
available)</p></li>
</ol></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="5"> Guardian</td>
<td colspan="11"> Fiduciary/Conservator</td>
<td colspan="16"><p>Durable Power of Attorney Health Care</p>
<p> Financial</p></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="32">8.7 Has the patient completed an advance directive? Yes
No (If yes, please place copy in Medical Record or send with
patient)</td>
<td colspan="4"></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 28%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 50%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>9. Skilled Care</strong></td>
<td colspan="10"><p><strong>10. Basic Activities of Daily
Living</strong></p>
<p><em>Code NO if the patient had ANY difficulty, required cueing or
supervision, or DID NOT do the task in the last 7 days</em></p></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2">Will the patient require these treatments
after referral?</td>
<td colspan="3" rowspan="2"><strong>YES</strong></td>
<td colspan="3" rowspan="2">In the last 7 days, has the patient required
<strong>help OR supervision</strong> to perform any of the following
activities<strong>?</strong></td>
<td colspan="9"><h1 id="last-7-days-1">Last 7 Days</h1></td>
</tr>
<tr class="odd">
<td colspan="5">Yes</td>
<td colspan="3">No</td>
<td></td>
</tr>
<tr class="even">
<td>9.1 CPAP/BiPap or Ventilator</td>
<td colspan="3"></td>
<td colspan="4">10.1 Bathing (tub bath, shower, or sponge)</td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>9.2 Oxygen</td>
<td colspan="3"></td>
<td colspan="4"><blockquote>
<p>10.1.1 Did the patient require physical assistance with bathing?</p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9.3 Suctioning</td>
<td colspan="3"></td>
<td colspan="4">10.2 Dressing (lower and upper body)</td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>9.4 Tracheostomy Care</td>
<td colspan="3"></td>
<td colspan="4">10.3 Eating (taking in food by any method, including
tube feedings)</td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9.5 Ostomy Care (not tracheostomy)</td>
<td colspan="3"></td>
<td colspan="4">10.4 Using the toilet (using toilet, urinal,
bedpan-getting on and off, cleaning self, managing devices used and
adjusting clothes)</td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>9.6 Dysphagia Diet</td>
<td colspan="3"></td>
<td colspan="4">10.5 Moving around in bed (moving to and from lying
position, turning side to side, repositioning)</td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9.7 Tube Feeding (any method)</td>
<td colspan="3"></td>
<td colspan="4">10.6 Transfers (moving to/from bed, chair, wheelchair,
standing)</td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td><p>9.8</p>
<p>9.8 Parenteral Feeding</p></td>
<td colspan="3"></td>
<td colspan="4">10.7 Moving around indoors (Answer yes even if with
cane, walker, or scooter - Answer NO if uses wheelchair OR did not get
around</td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9.9 IV Infusions</td>
<td colspan="3"></td>
<td colspan="4"><ol start="8" type="1">
<li><p>If uses wheelchair, moving around chair (propelling and
maneuvering)</p></li>
</ol>
<p>Code YES if the patient can maneuver wheelchair by him/herself (even
if it is a power chair)</p></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>9.10 Medications by Injection</td>
<td colspan="3"></td>
<td colspan="4"><ol start="9" type="1">
<li><p>Do any of the answers above (a-g) indicate a recent (2-3 mos)
change in functioning?</p></li>
</ol>
<p><em>Code yes if the patient’s function has significantly changed in
the recent past</em></p></td>
<td colspan="5"><p><strong>YES</strong></p></td>
<td colspan="3"><strong>NO</strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9.11 Urinary Catheter Care</td>
<td colspan="3"></td>
<td colspan="4"><h1 id="continence">11. CONTINENCE</h1></td>
<td colspan="8"><h1 id="yes-1">YES</h1></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td>9.12 Dialysis –- Center based</td>
<td colspan="3"></td>
<td colspan="4"><blockquote>
<p>11.1 Is the patient incontinent of urine?</p>
</blockquote></td>
<td colspan="8">Yes No </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>9.13 Dialysis – Home -based</td>
<td colspan="3"></td>
<td colspan="4"><blockquote>
<p>11.2 Is the patient incontinent of stool?</p>
</blockquote></td>
<td colspan="8">Yes No</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">9.14 Wound Care (other than pressure ulder)</td>
<td colspan="5"></td>
<td colspan="3"><h1 id="skin">12. SKIN</h1></td>
<td><strong>YES</strong></td>
<td colspan="7"><strong>NO</strong></td>
</tr>
<tr class="even">
<td colspan="2">9.15 Pressure Ulcer Care</td>
<td colspan="5"></td>
<td colspan="3"><blockquote>
<p>12.1 Has the patient experienced any troubling skin problems like
burns, bruises, or itching in the last 30 days?</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="7"><p>9.16 Check the stage of the <strong>worst</strong>
pressure ulcer</p>
<p>1 2 3 4 </p></td>
<td colspan="3"><strong>13. Patient Behaviors and Symptoms</strong></td>
<td colspan="8"><strong>Last 7 days</strong></td>
</tr>
<tr class="even">
<td colspan="2">9.17 Frequent Nurse Observation (more than 1/week)</td>
<td colspan="5"></td>
<td colspan="3">In the last <strong>7</strong> days, has the patient
exhibited any of the following?</td>
<td colspan="8"><h1 id="section"></h1></td>
</tr>
<tr class="odd">
<td colspan="2">9.18 Physical, Speech, Occupational or
Kinesiotherapy</td>
<td colspan="5"></td>
<td colspan="3"><ol type="1">
<li><p>Wandering (moved with no rational purpose, seemingly oblivious to
needs or safety)?</p></li>
</ol>
<p>Wandering is purposeless movement often without regard to safety.
Pacing up and down is NOT wandering.</p></td>
<td colspan="8">Yes No</td>
</tr>
<tr class="even">
<td colspan="2">9.19 Alcohol, Drug, or other substance abuse
treatment</td>
<td colspan="5"></td>
<td colspan="3"><ol start="2" type="1">
<li><p>Verbally abusive behaviors (threatened, screamed at, or cursed at
others)?</p></li>
</ol>
<p><em>Code if any such behavior occurred, regardless of patient’s
intent.</em></p></td>
<td colspan="8">Yes No</td>
</tr>
<tr class="odd">
<td colspan="7">9.20 Other (specify)</td>
<td colspan="3"><p>13.3 Physically abusive behaviors (hit, shoved,
scratched or sexually abused others)?</p>
<p><em>Code if any such behavior occurred, regardless of patient’s
intent.</em></p></td>
<td colspan="8">Yes No</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2">9.20 Other (specify)</td>
<td colspan="3">13.4 Resisting care (resisted taking medications
/injections, ADL assistance, eating, or changes in position)?</td>
<td colspan="8">Yes No</td>
</tr>
<tr class="odd">
<td colspan="3"><ol start="5" type="1">
<li><p>Hallucinations or delusions?</p></li>
</ol>
<p><em>Hallucinations are <strong>sensory</strong> (auditory, visual,
olfactory, tactile) experiences that are NOT</em></p>
<p><em>Delusions are <strong>ideas or beliefs</strong> that are held
even though there is no evidence to support them or evidence that shows
them to be false</em>.</p></td>
<td colspan="8">Yes No</td>
</tr>
<tr class="even">
<td colspan="18"><strong>14. Cognitive Status</strong></td>
</tr>
<tr class="odd">
<td colspan="18"><h1
id="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">14.1
In the last <u>7</u> 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?</h1>
<p>Yes Patient consistently made reasonable decisions <strong>without
difficulty</strong></p>
<p>No Patient made decisions <strong>with difficulty</strong> OR did not
make decisions OR decisions were poor</p></td>
</tr>
<tr class="even">
<td colspan="18"><h1
id="in-the-last-7-days-has-the-patient-usually-been-able-to-make-himherself-understood">14.2
In the last 7 days, has the patient usually been able to make
him/herself understood?</h1>
<p>Yes – Patient’s expression of information is understood, even if s/he
has difficulty in finding words or finishing thoughts</p>
<blockquote>
<p>No – Patient’s expression of information is never (or rarely)
understood OR s/he is limited to making concrete requests</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="18"><h1
id="in-the-last-90-days-has-the-person-become-so-agitated-or-disoriented-that-his-safety-was-endangered-or-she-required-protection-by-others-as-a-result">14.3
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?</h1>
<p>Yes No </p></td>
</tr>
<tr class="even">
<td colspan="10"><h1 id="prognosis">15. Prognosis</h1></td>
<td colspan="8"><h1 id="yes-2">Yes</h1></td>
</tr>
<tr class="odd">
<td colspan="10">15.1 In the last 7 days, has the person experienced a
flare up of a recurrent or chronic health problem?</td>
<td colspan="8">Yes No</td>
</tr>
<tr class="even">
<td colspan="10">15.2 Does the direct care staff (MD, rehab therapist)
think the patient is capable of increased independence (in ADLs, IADLs,
or mobility)?</td>
<td colspan="8">Yes No</td>
</tr>
<tr class="odd">
<td colspan="10">15.3 Does the patient have a limited life expectancy
(likely to be less than 6 months)?</td>
<td colspan="8">Yes No</td>
</tr>
<tr class="even">
<td colspan="18"><strong>16. Weight Bearing</strong></td>
</tr>
<tr class="odd">
<td colspan="18"><blockquote>
<p>16.1 What is the patient’s weight bearing status? Full Partial
None</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="18"><h1 id="diet"> 17. Diet</h1></td>
</tr>
<tr class="odd">
<td colspan="18"><blockquote>
<p>17.1 Diet Regular Modified (Specify diet)</p>
</blockquote></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 15%" />
<col style="width: 1%" />
<col style="width: 17%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12"><blockquote>
<p><strong>18. What equipment does the patient need? (Please Place
Prosthetics Requests)</strong></p>
</blockquote></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"><blockquote>
<p>18.1 Hospital Bed</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>18.3 Trapeze</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>18.5 Cane</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p>18.7 ADL equipment</p>
</blockquote></td>
<td colspan="4" rowspan="2"><blockquote>
<p>18.9 Other (specify)</p>
</blockquote></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p>18.2 Special mattress</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>18.4 Walker</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>18.6 Wheelchair</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p>18.8 Orthotic or splint</p>
</blockquote></td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><strong>19. What supplies does the patient need?
(Please place orders for supplies)</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p>19.1 Catheters</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>19.3 Dressings</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>19.5 Tape</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p>19.7 Ostomy supplies</p>
</blockquote></td>
<td colspan="4" rowspan="2"><blockquote>
<p>19.9 Other (specify)</p>
</blockquote></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><blockquote>
<p>19.2 Tubing</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>19.4 Wrappings</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>19.6 Glucose strips</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p>19.8 Saline</p>
</blockquote></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6"><strong>20. Goals of Care (check as many as
apply)</strong></td>
<td colspan="7"><strong>21. Referring to which program? (Check as many
as apply)</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><p>20.1 Rehabilitation (improved function)</p>
<p>20.2 Skilled nursing care (e.g., manage wounds, medical devices,
catheters, ostomy)</p>
<p>20.3 Monitoring/supervision to avoid clinical complications</p>
<p>20.4 Improve compliance with medications/treatments</p>
<p>20.5 Patient/Family Education</p></td>
<td colspan="4"><p>20.6 Respite (temporary relief for caregiver)</p>
<p>20.7 Palliation/End of Life Care</p>
<p>20.8 Reduce hospitalizations and/or ER visits</p>
<p>20.9 Supervised/supportive living situation</p>
<p>20.10 Behavior Stabilization</p></td>
<td colspan="3"><p>21.1 Skilled care in home</p>
<p>21.2 Home Based Primary Care (HBPC)</p>
<p>21.3 ADL assistance (personal care) in home</p>
<p>21.4 Chore Services (homemaker) in home</p>
<p>21.5 Adult Day Health Care</p>
<p>21.6 Residential care (supervised living)</p>
<p>21.7 Assisted Living</p>
<p>21.8 Domiciliary care</p>
<p>21.9 Short-term nursing home care (subacute care, rehab,
etc)</p></td>
<td colspan="4"><p>21.10 Long-term nursing home care</p>
<p>21.11 Outpatient Respite care</p>
<p>21.12 Inpatient Respite care</p>
<p>21.13 Specialized Dementia or Geropsych Care</p>
<p>21.14 Inpatient palliative/hospice care (in NHCU )</p>
<p>21.14 Outpatient Palliative/ hospice care (in home)</p>
<p>21.16 All inclusive care or PACE program</p>
<p>21.17 Other_______</p></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>22. ESTIMATED DURATION OF
SERVICES?</strong></td>
</tr>
<tr class="even">
<td>22.1 1 week</td>
<td colspan="4">22.2 2-3 weeks</td>
<td colspan="2">22.3 One month</td>
<td>22.4 2-3 months</td>
<td colspan="3">22.5 4-6 months</td>
<td colspan="3">22.6 Indefinite</td>
</tr>
<tr class="odd">
<td colspan="14"><strong>Comments.</strong> (Any additional information
that may be helpful to the referral program)</td>
</tr>
</tbody>
</table>

+----------------------+------------+-------------------+-------------+
| **This Section for   |            |                   |             |
| Administrative Use   |            |                   |             |
| Only Use This        |            |                   |             |
| Section Referral is  |            |                   |             |
| processing (Check as |            |                   |             |
| many as apply)**     |            |                   |             |
+----------------------+------------+-------------------+-------------+
| Where was the        |            |                   |             |
| patient referred?    |            |                   |             |
+----------------------+------------+-------------------+-------------+
| **Home Care**        | **Funding  | ##                | **Funding   |
|                      | Sources    | ###### Structured | Sources for |
|                      | for Home   |  Living Situation | Structured  |
|                      | Care**     |                   | Living      |
|                      |            |                   | Situation** |
+----------------------+------------+-------------------+-------------+
| Community Skilled    | VA         | Personal Care     | VA          |
| Home Health Care     |            | Home              |             |
+----------------------+------------+-------------------+-------------+
| VA Home-Based        | Medicare   | Community         | Medicare    |
| Primary Care         |            | Residential Care  |             |
+----------------------+------------+-------------------+-------------+
| Homemaker/Home       | Medicaid   | Assisted Living   | Medicaid    |
| health aide          |            |                   |             |
+----------------------+------------+-------------------+-------------+
| VA Bowel and Bladder | Other      |                   | Other       |
|                      | insurance  |                   | insurance   |
+----------------------+------------+-------------------+-------------+
| Adult Day Health     | Private    |                   | Private Pay |
| Care                 | Pay        |                   |             |
+----------------------+------------+-------------------+-------------+
| VA in-home respite   | Other      |                   | Other       |
|                      | (specify)  |                   | (specify)   |
+----------------------+------------+-------------------+-------------+
|                      |            |                   |             |
+----------------------+------------+-------------------+-------------+
|                      |            |                   |             |
+----------------------+------------+-------------------+-------------+
| **Domiciliary**      | **Funding  | ########          | **Funding   |
|                      | Sources    | Nursing Home Care | Sources for |
|                      | for        |                   | Nursing     |
|                      | Dom        |                   | Home Care** |
|                      | iciliary** |                   |             |
+----------------------+------------+-------------------+-------------+
| VA Domiciliary       | VA         | VA NHCU (Rehab)   | VA          |
+----------------------+------------+-------------------+-------------+
| State Home           | Medicare   | VA NHCU           | Medicare    |
| Domiciliary          |            | (Long-term care)  |             |
+----------------------+------------+-------------------+-------------+
|                      | Medicaid   | VA NHCU (subacute | Medicaid    |
|                      |            | care)             |             |
+----------------------+------------+-------------------+-------------+
|                      | Other      | VA NHCU (respite) | Other       |
|                      | insurance  |                   | insurance   |
+----------------------+------------+-------------------+-------------+
|                      | Private    | Community nursing | Private Pay |
|                      | Pay        | home              |             |
+----------------------+------------+-------------------+-------------+
|                      | Other      | State Veterans    | Other       |
|                      | (specify)  | nursing home      | (specify)   |
+----------------------+------------+-------------------+-------------+
|                      |            | VA NHCU (Hospice) |             |
+----------------------+------------+-------------------+-------------+
| **Hospice Care**     | **Funding  | ######## G        | **Funding   |
|                      | Sources    | eriatric Services | Sources for |
|                      | for        |                   | Geriatric   |
|                      | Hospice    |                   | Services**  |
|                      | Care**     |                   |             |
+----------------------+------------+-------------------+-------------+
| VA NHCU (Hospice)    | VA         | GEM Clinic        | VA          |
+----------------------+------------+-------------------+-------------+
| VA Outpatient        | Medicare   | Geriatric Primary | Medicare    |
| hospice              |            | Care Clinics      |             |
+----------------------+------------+-------------------+-------------+
| Community hospice    | Medicaid   | VA GEM inpatient  | Medicaid    |
|                      |            | unit              |             |
+----------------------+------------+-------------------+-------------+
|                      | Other      |                   | Other       |
|                      | insurance  |                   | insurance   |
+----------------------+------------+-------------------+-------------+
|                      | Private    |                   | Private Pay |
|                      | Pay        |                   |             |
+----------------------+------------+-------------------+-------------+
|                      | Other      |                   | Other       |
|                      | (specify)  |                   | (specify)   |
+----------------------+------------+-------------------+-------------+
|                      |            |                   |             |
+----------------------+------------+-------------------+-------------+
| **Care               | **Funding  | **OTHER           | **Funding   |
| Coordination/Home    | Sources    | (specify)**       | Sources for |
| Telehealth**         | for        |                   | Other**     |
|                      | Hospice    |                   |             |
|                      | Care**     |                   |             |
+----------------------+------------+-------------------+-------------+
| Care                 | VA         |                   | VA          |
| Coordination/Home    |            |                   |             |
| Telehealth           |            |                   |             |
+----------------------+------------+-------------------+-------------+
|                      | Medicare   |                   | Medicare    |
+----------------------+------------+-------------------+-------------+
|                      | Medicaid   |                   | Medicaid    |
+----------------------+------------+-------------------+-------------+
|                      | Other      |                   | Other       |
|                      | insurance  |                   | insurance   |
+----------------------+------------+-------------------+-------------+
|                      | Private    |                   | Private Pay |
|                      | Pay        |                   |             |
+----------------------+------------+-------------------+-------------+
|                      | Other      |                   | Other       |
|                      | (specify)  |                   | (specify)   |
+----------------------+------------+-------------------+-------------+
|                      |            |                   |             |
+----------------------+------------+-------------------+-------------+