Malnutrition Toolkit Survey 

Carroll

MAC

Baltimore

Washington

INTRO: Please review the Malnutrition Toolkit prior to filling out this survey. You should also have the toolkit available and be able to reference it section-by- section as you respond to this survey. 

1) Your name

2) Select your AAA

a) Baltimore City

b) Carroll County

c) MAC

d) Washington County

3) Select your position/role in your AAA? (select all that apply)

a) Executive Director

b) MAP

c) Nutrition

d) Health Promotion

e) SHIP

f) Senior Care

g) Other

Rationale for Community-Based Interventions (pages 3-5)

4) Please review the risk factors for malnutrition listed in this section. How often do you interact with individuals who have one or more risk factors for malnutrition? 

a) Never

b) Rarely

c) Sometimes

d) Fairly often

e) Frequently 

5) Malnutrition can lead to...? (Check all that apply)

a) Increased healthcare costs

b) Increased risk of falls 

c) Increased hospital readmission rates  

d) Loss of independence and frailty 

6) Social determinants of health are associated with risk for malnutrition.

a) True

b) False

Step 1: Implement Validated Screening Tools (pages 12-14)

7) Why should AAAs screen clients for malnutrition and other health risks? 

a) To help heal the condition(s) and allow older adults to remain in the community.

b) To make the most appropriate referrals clients need to improve their physical and mental health.

c) Because AAAs have services that address the conditions screened for, and we refer clients to medical experts in addition to the community supports we offer.

d) All of the above.

8) What screening tools does your AAA already use? (Check all that apply)

a) Level One Screen

b) DETERMINE checklist

c) HDM Priority Screening

d) Other: Fill in

Step 2: Address Root Causes (pages 15-17)

9) Look at the chart provided in this section. Please list other services/programs that you offer that are not listed to address social determinants of health?

a) Food and Nutrition: Fill in

b) Housing: Fill in

c) Transportation: Fill in

d) Financial: Fill in 

e) Utilities: Fill in

f) Personal Safety: Fill in 

g) In-Home Care: Fill in

h) Social Supports: Fill in

i) Mental Health: Fill in

j) Health Care Referral: Fill in

k) Employment: Fill in

l) Health Education: Fill in 

Step 3: Monitor Client Progress and Quality of Services (pages 18-21)

10)  Why is it important to follow up with clients? (Check all that apply)

a) Track progress towards established goals and outcomes

b) Provide encouragement and positive reinforcement 

c) Re-screen for continued unmet needs and additional referrals

d) Ensure quality of services provided 

Professional Roles & Responsibilities (pages 21-22)

11)  Please observe your role on the chart provided. Do you feel that the suggested roles are appropriate based on your job duties? What might you remove or add?  (Executive Director, please look at the chart overall and provide comments regarding any section). Fill in.

Strategies for Moving Forward (pages 23-29)

12)  Which of the three partnership scenarios seems most feasible for your organization?

a) Partnering with insurance companies

b) Regional partnerships

c) Partnering with hospitals and CTOs

d) I’m not sure (N/A) 

13)  Please look at the separately provided 3-page list of ICD-10 codes. Please list up to three Z codes that might fit with services you are already providing.

a) Fill in 

b) Fill in

c) Fill in 

Appendices 

14)   What is the most useful resource or section for you? What is missing? Fill in

Overall 

15)   What pieces of the toolkit did you find most helpful and why? What suggestions do you have regarding how to improve the toolkit?**

16)   Overall, how would you rate the toolkit?

a) Poor - needs a lot of work

b) Fair - needs quite a bit of work, but on the right track

c) Good - almost there! 

d) Excellent - high quality, ready for sharing with AAAs

e) Comment box