The Home & Community Care Program is jointly funded by the Commonwealth and Victorian governments

Name: Checklist Date of Birth: / / Gender: UR Number: Organisation Or affix label here

Date of assessment: / / Assessed by: Signed: Other participants involved in assessment Relationship to client: Who was the main provider/s of information for the Assessment:

 Item Notes/referrals agreed to Intake information/consumer details Not included in this tool – refer to SCTT consumer details or organisation specific intake information. Referring agency screening information Not included in this tool- refer to SCTT referral information received other agency referral information. Personal story

Health management

o Health status

o Cognition and psychosocial

o Lifestyle and decision makings

Managing everyday activities

Carer health and well being

Accommodation and safety

Supplementary validated screening tools: • K-10; anxiety and depression • Malnutrition screening tool

• ASSIST tool screens for use of alcohol, tobacco and other psychoactive drugs – Malnutrition screening tool Care plan developed Yes No Date of care plan / /

Review date / /

Produced by the Victorian Department of Health & Human Services, 2015 HACC assessment tool – Page 1 of 21  withthis? doyouHow getoutandabout?areyou managing Communityaccess Who arethepeoplethat  lookforward to? foryou?What isworkingwell doyou mostenjoy and  What ismostimportanttoyouWhy? rightnow? used todo?) ( recentlychangedforyou? Why areyouWhathas seekingsupportrightnow? andhowisthisworkingforyou)? (e.g. Whodoyoulivewith areyouHow managingathome? Initialengagement Personal story Note: Note: Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced e.g. recent hospital episode, fall, stressful event, change in carer circumstances, stopped doing something you doingsomething incarercircumstances,stopped episode,fall,stressfulevent,change e.g. recenthospital Prompts: Prompts: Prompt: Validate and build on information collected at intake or from other agencies.from other Validatebuildor and on intake information collected at

Does anyone assist you to get around – family, friends, formalaroundfamily, – friends, support?you get to assist Does anyone companiontaxi card) sticker,you use (disability card, drive, public Do transport? Is there anything you would like to change or likeaboutthere changeimprove to wellbeing/lifestyle?youyour anything would Is Dodo well?you any keep you animals/pets? Howhave working wouldyou? is not What thingsyou well of for like improve? to sort What 2 of 21of especially importanttoyou?meabouttheserelationships. Tell Organisation UR Number: Gender: Birth: Date of Name :

/

/ /

Or affixlabelhere

Personal story  Bywho? Any otherrecentassessments? for you? you athome?Are theseworkingwellforyou/not working anyservicesto assist Are you currentlyreceiving Currentservices toyou?be aware ofinprovidingservices considerationsthatare important forusto valuesorbeliefslifestyle Do you haveany cultural,religious needsDiverse at risk, signsofstress? orwellbeing E.g.carerhealth ortheclientscareresponsibilities? aboutthecarerelationship Are thereany concerns Assessor rated: areyouHow managing? type ofcaredoyou provide? If yes,doyou careforandwhat who Do you haveany caringresponsibilities? working foryou? helpsyou? supportperson(s)who Are thesearrangements Do you haveacareror Carerprofile The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Prompt:

Yes No HACC and non HACC services, informal and formal supports e.g. respite, allied health, rehabilitation, case manager.alliedhealth, respite,rehabilitation, case HACCand and informalsupports e.g. HACC services, non formal If yes , complete the Carer health and wellbeingsection theCarerhealthand , complete 3 of 21of

Yes No (this refers to the client as acarer) (this referstotheclientas

Personal story  foryou?a typical week islike what orattendsocial/communitygroupsclubs?Describe family/friends oftendoyouHow catchupwith  andspecialinterests. communitynetworks Describe your socialand Socialand networks community occupations; What areyour presentandpast Occupation/career history/volunteerhistory The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Prompts: Prompts: What is stopping you from getting out more?getting outyou fromis stopping What havebecause really weekbecausetonotyoudo things eachwant – to you theyou are What youdo toagain?reallydoingor would enjoydo like What you?to providewhat support do forandthey you provide others support do What communities? networks/ these do you role play in What 4 of 21of current orpreviousvolunteerwork?

Personal story Action required If yes, Do you havealongtermdisability? you doingtoroutinelymanageyour healthcondition(s)? areyouthings How managing–what Note: Listother conditions: Forexample doyou have… Do you haveany healthconditions? upinthelast12 months? Have you hadaGPcheck wellbeing? doesthisimpactonyour andhow overall Which activitiesaremostaffected in thelast4weeks? activities(outsideorinsidethehouse) muchdidyourHow healthaffectyour normal  you mostconcernedabout? What aspectsofyour healthare theof assessment complexity or length Note: is you sayIn general,would your health Healthand wellbeing Health management Health Status Health Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced

Prompt: Prompt:

Other health conditions (If the client isachildlisthealthcondition/s.) conditions(Iftheclient Other health pressure(hypertension) High blood health Mental Diabetes disease) (cardiovascularorheart Heart problems Allergies conditions orothermusculoskeletal Osteoporosis Arthritis Yes Not atall what is it and how are you managing? How does it affect your health, lifestyle and wellbeing? itaffectyourhealth,lifestyleand youmanaging?How does whatisitandhoware the impact this is having on performing daily tasks and tasks dailyactivities.is having on the performing social this impact discuss and information on gather health to conditions medicaldiagnosis, aisnot of make but to The role HACC assessor listed herean that exampleidentifyas conditions conditionis not the maya aand person This health list of is notcomplete If the person reports ‘fair’ or ‘poor’ this would indicate the potential for poor health outcomes outcomes and potentialpoor wouldperson‘fair’or health for this indicate the‘poor’ the reports If What is good about you health-wise? is good What No

Slightly

Yes Not stated/unknown Notstated/unknown No 5 of 21of Moderately Yes Organisation UR Number: Gender: Birth: Date of Name Excellent A great deal Agreat : Don’t have aGP Don’thave No

Cancer -type MS Parkinson’s disease Stroke Chronic kidney disease (respiratoryconditione.g.asthma) Breathing problems, Memory loss

Very Good Very Good /

/ /

Good Fair Or affixlabelhere the potential the potential Poor Health manage ment . Action required If yes, Suchaschewingyour food? Do you haveany problemsswallowing? orunderweight? e.g. obviousoverweight Do you haveany othernutritionalconcerns  shoppingforfood,preparingmeals? areyouHow managingwith  If yes,underweight inthelast6months? Have youtrying lostorputonany weightwithout  changes orconcerns? isyourHow appetite?Anyrecent Nutrition / Swallowing Action required with currentsupports? essentialmedication Can thepersonmanage prescribedmedication? care of herorhisown  Assessorrated:  pack orsimilar –e.g.webster pack? Do you useamedicines medications? Can youmehow show manageyour you withmanagingyour medications? Does anyone assist aretheyworking for you? In your opinionhow (prescribedoroverthecounter)? Do you takeany medicines MedicinesManagement The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced   Prompt: Prompt: Check if the Prompts:

Observe if the person’s clothes fit wellperson’s fitif theclothes Observe Observe/look for evidence of fresh food in the evidence home? in for fresh food of Observe/look Does the person generally look after andtake persongenerallylook Does the is this contributing to the person’s change in appetite? person’s changeinappetite? isthiscontributingtothe Has the GP conducted a review of recently? theaof medicines theconductedreview GP Has 5than moremedicines.polypharmacypeopleissuesof with for Consider Do you have any special dietary requirements? any you special have dietaryDo , explore reasons , explore

Yes Yes 

person is clear about their medicines – what they are taking them for etc.medicines theirwhat them for person they – taking are about is clear HACC MDS HACC No No 6 of 21of

and consider using the MST tool to screen for level ofmalnutritionrisk theMSTtooltoscreenforlevel andconsiderusing

No Yes without help unabletotakeown medications Completely orreminds) (e.g.issomeone prepares With somehelp righttime) (intherightdosesat Without help

Yes

Yes Yes No No

No Yes If yes Yes , who? No No

Health manage ment Action required If yes  majorskinconditions? Do you currentlyhaveany Skinconditions Action required youmedicine totohelpsleep? Doyou require insufficient sleep? fragmentedsleep, difficultieswithyour sleepe.g.difficulty fallingasleep, Do you experienceany Sleep Action required  managepain? What strategiesdoyou usetohelp socialising,sleeping? activitiessuchaswalking, doesthepainimpactonyourHow day-to-day If yes you rateit howwould Do you haveany pain? Pain Action required dentalcheck-up? Have you hadarecent If yes, you noticedanylossoftaste? painorsoreteethwhen you eat?Have Do you experienceany teeth,mouthordentures? Do youyour haveany problemswith Oral health Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced

Prompt: If yes, Prompt: If Prompt:

Other skin problems Other skin surgical woundsHealing ulcer Pressure Not atall None , specify is this contributing to the personschangeinappetite? isthiscontributingtothe Who is assisting you to you manage to pain?your is assistingWho Verymild Who is assisting you to manage thisisassistingWho you managecondition?to Verylittle Yes Yes Yes Yes Yes e.g. bruising, rashes, itching,eczema etc… e.g. bruising,rashes, No No No No 7 Yes of 21of ( see rating scale see rating Consider a referral to GP physiotherapist, painclinic areferraltoGPphysiotherapist, Consider Moderate No Moderately No If yes,

Otherskin tears,cuts,lesions Otherskin ulcer )? Yes Severe Severe where is it? How long have you had thispain/whendiditstart? isit?Howlonghaveyouhad where

Alot

Yes No Yes VerySevere No Severely

No Yes No

Health manage ment Action required aid? your ahearing Do you havetroublewith hearing?Withorwithout Hearing  If yes, withglasses? Do you havedifficultyvision,even with Vision o o Action required Are you afraidoffalling? yesIf Not (insideoroutsidethehome)inlast12months? Have you hadoneormorefalls Falls Action required Do you haveregularpodiatry appointments? your ormoveabout? abilitytowalk Do you haveafootproblemthataffects Feet The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Prompt: Prompt: conditions such as arthritis, diabetes, stroke, memory loss, foot problems diabetes,stroke,memoryloss,foot conditions suchasarthritis, allied healthprofessional. planbyGPor forafallsriskassessmentorprevention andconsiderareferral and theclientsADLstatus

Never e: A referral to a falls clinic should be considered if the person has significant difficulties with ADLs, chronic significantdifficultieswithADLs,chronic ifthepersonhas toafallsclinicshouldbeconsidered A referral hashadafallorindicates If theperson

, do you know what caused the fall(s)? e.g. Trip, slip, blackout, dizziness thefall(s)?e.g.Trip,slip,blackout, , doyou know whatcaused for PAV assessment this question is ‘falls in the lastquestionin months’assessment this the6 foris ‘falls PAV when did you last have youreyeschecked? whendidyoulasthave For referral or ask if the person is already linked in to Vision toAustralialinkedthe referral ask is already inperson orif For Rarely Yes Yes Yes No No No Sometimes Sometimes 8 of 21of sometime Often

Yes s or

often often No Yes to being afraid of falling,examinethecircumstances to beingafraidof

No

Yes

Yes No Yes No No

Health manage ment a power of attorney seek advice from the Office of the Public Advocate. theOffice of Public from powerattorney theofseek aadvice Note: Action required of makingtheirown decisions? Is theclientcapable Assessorrated: Action required ofdementia? Is thereamedicaldiagnosis Dementia diagnosis Action required memory loss? with behaviouralsymptoms associated aboutpsychological or Are thereany concerns ordementia? memoryloss,cognitivedecline,confusion Is thereevidenceof Assessorrated: behaviouralchanges? orassistancetomanagethese Are you currentlygettingany help insomnia inhibition,apathy, calling out, include:These could personalsupportstaffifpossible informationfromthecareror Consider obtaining impactingontheperson,family, carer. what behavioursandhowtheseare If thereareconcerns,elicit If yes living? family everyday impactingonthepersonandtheircarer’sand/or If thereismemory loss,howisthis for:Observe/look person’s GP investigatedbythe period –hasthisbeen oroveralonger e.g.suddenchange thetimeframeofanychanges inmemoryandthinking Ask aboutchanges isyourHow memory? thereIf are for wellbeingconcernscomplete carer Carerthehealth and wellbeing section Memoryand thinking Cognition and psychosocialand Cognition Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced

If there are no enduring powers of attorney and there is reasonable doubt as to whether the person has capacity to appoint to has person capacity as and the is reasonable whether doubtto there there powersattorney no of Ifare enduring , have you or anyone else noticed any behavioural changes associated withyour memoryloss? changesassociated you oranyone elsenoticedany behavioural , have Signs of self-neglect? Not aware of time and awaretimeplace? of Signs Not self-neglect? of Yes Yes Yes Aggression, wandering, sun-downing, shadowing, inappropriate exposure, hoarding, agitation, sexualagitation, hoarding,dis- shadowing,inappropriatewandering, exposure,Aggression, sun-downing, No No No 9 of 21of Consider referraltoDBMAS,AAVetc. Consider If no

, consider areferraltoGP,CDAMSACAS , consider

Yes No

.

Not sure No Yes No Yes No Yes

Health manage ment Action required screening yes,considerK-10forIf further lack of motivation? sadness,anxietyhopelessness, Are theresignsoflow mood, Assessorrated: managing? arethecarers,family How family?receive any supportfromcarer, Doyou lifeandwellbeing? doesthisaffectyour managing?How everyday If yes, howareyou currently Do you oftenfeelnervousoranxious? Do you oftenfeelsadordepressed? If yes victimloss, crimeof includeThese could overthepast12months? oneormoremajorstressfullifeevents Have you experienced Psychosocial The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced , specify event(s) and explore how this impacts ontheclient’shealthandwellbeing. event(s)andexplorehowthisimpacts , specify : Yes A bereavement or severe illness/injury of self/family/friend, separation from separationpartner/family, major financial severe self/family/friend, illness/injury of from bereavement or A No 10 of 21of Yes Yes No No

unknown unknown

Yes Not stated/ No Yes

Health No manage ment andotherdrugs onuseofalcohol ASSISTscreentogatherfurtherinformation Consider usingthe Action required foryou thatyou liketodiscussfurther? would Are anyoftheseanissue aboutyour useofdrugs? Do you haveany concerns Do you currentlysmoke? drinksononeoccasion? oftendoyouHow have6ormorestandard much alcoholyou abouthow drink? Do you haveany concerns Alcohol smoking and Action required What isstoppingyou fromdoingit? enjoydoingmost?Wouldyou liketodomore? What physical activity doyou aboutyour levelofphysical activity?Do you haveany concerns orbalance? inattendingactivitiestoimproveyour strength balance? Wouldyou beinterested e.g.toimprove prescribedby ahealthprofessional suchastaichiorexercises Do you attendany activities gardening,housework walking, toraiseyour breathingrate)?E.g. activityhaveyou done(enough In thepastweek howmuchphysical Physicalactivity Action required  Would you liketodiscussthisfurther? concernsregardinggambling? Do you oryour familyhaveany have? than theyusedto D concerns/issues? Do you haveany financial Managingfinances Lifestyle and decision making decision and Lifestyle Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced

Prompt: Prompt: oes the person appear to be worried about money? Has the person mentioned losing money orhavinglessmoney mentionedlosingmoney money?Hastheperson tobeworriedabout oes thepersonappear

Never smoked Never smoked Never Is a counsellor a Is required? Less than monthly Lessthan Yes Yes Yes Hasquitsmoking No No No 11 of 21of . Monthly (explore barriers) (explore Currently smokes Currently Weekly Yes

No Yes Daily or almost daily Daily oralmost

No Yes Yes Yes No No No Notexplored

Health manage ment Assessornote/observations Doesthisincludea Treatment orof Refusal other Certificate documentation limiting treatment? o o CarePlan? Do you haveanAdvance Note: Sighted Do you haveany ofthefollowing… you inmakingfinancialdecisions? Does anyone assist you inmakinghealthorlifestyle decisions? Does anyone assist Decisionmaking The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced services assistancethat ACPprovide withtheircatchment in be found:can anininformal family establishedsetting or via an ACP agedhealth program a service, within GP.care setting or awith sitethe theis of notIt ACP. role HACC a assessoranclient. to ACP the with develop Developingantake ACP canplace

Yes Yes If a person a If expresses interest an developingyou ACP in or asks further for information,contact of details some health person theanIf ACP has thisshould if bepossible noted and notewheredoit Younot is kept. to needor forsearch

is sighted, simply note that client and or carer reports that the powerattorney. hasof reports person a orthat client andcarer is sighted, that simply note It is important to be accurate in what you may note about legal matters such as Powers of Attorney. Unless documentation Attorney. documentation PowersofUnless such as about note legal what matters you bemayto accurate in is important It No No Yes Not stated/unknownNot No 12 of 21of If yes

General Powerof Attorney General EPOA –Guardianship Treatment EPOA –Medical EPOA –Financial , where is thiskept? is , where If yes

, who?

If yes Yes www.health.vic.gov.au/acp

, who? Yes

No Unsure None Advocate Administrator Guardian

No Yes Notstated/unknown No .

Health manage ment Assessor Notes:   bills)    ambulance)   in place with anyaids ratetheperson’scurrentcapacity For HACCMDSpurposesassessors Activity – Daily activities . activities everyday Managing The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Home mainetenance( Telephone Money management/banking Meal preparation Shopping Transport Housework

Completely unabletodo Completely With somehelp Without help unabletousethetelephone Completely With somehelp of assistivedevices) phonecallsincludinguse (making andreceiving Without help money unabletohandle Completely paying with chequebook and buying butneedhelp (manage day-to-day With somehelp track of finances) bills,banking, keeping (writing cheques,paying Without help managenutrition preparation,servingor unabletodoany meal Completely With somehelp of mealsandserving) cooking, adequacy (planning,preparing, Without help unabletodo Completely trips) togowith clientonallshopping some help(needsomeone Needs careof allshoppingneeds Can take vehiclelikean aremade for aspecialised unable(unlessarrangements Completely travelling) helporaccompany when (needsomeoneto With somehelp ortaxis) onpublictransport (drivesown car,travelsindependently Without help unabletodohousework Completely some help/supervision Needs laundry) orsupervision(including housewithouthelp Can maintain

Assessor rated Assessor

(assumes transportisavailable)

(Consider reablement buildingand (Consider reablement capacity opportunities) 

HACC MDS HACC item MDS Gardening, lawn mowing, gutter clearing) mowing, Gardening, lawn gutter 13 of 21of

Organisation UR Number: Gender: Birth: Date of Name :

/

/ /

task? this with help anyone Does

No Yes No Yes No Yes No Yes No Yes No Yes No Yes Or affixlabelhere

Managing Required Action

No Yes No Yes No Yes No Yes No Yes No Yes No Yes everyday activities     in place with anyaids ratetheperson’scurrentcapacity For HACCMDSpurposesassessors rated Activity –Assessor PersonalCare Assessor Notes: areneeded? howmany people If assistancewithtransfersneeded,  cornering including independently help’,ifthepersonmanages If inawheelchair,tick‘with some crutches  in place with anyaids ratetheperson’scurrentcapacity For HACCMDSpurposesassessors rated Activity –Assessor andMobility transfers The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Toilet use Eating Dressing Bathing (showering) shower Transfers –bed,chair,toilet, Mobility athome

Completely unable to manage toileting without help unabletomanage Completely With somehelp dressingandcleansself) (includesonandoff, Without help help(e.g.spoonfeeding) unabletoeatwithout Completely pouringdrink) food,spreadingbutter, (e.g.helpcuttingup With somehelp Without help unabletodress Completely alone) etc..butcanputonsomegarments (e.g.helpwith buttons With somehelp laces) (includingbuttons,zips, Without help help unabletobathewithout Completely inandoutofbath) (e.g.needshelpgetting With somehelp unsupervised) of showerorbathandwashing (includeinandout Without help tomanage(nosittingbalance) Unable some help Needs needed No help andmustbepushed. unabletowalk. Useswheelchair Completely or verbal),orwith theuseofawalker from aperson(physical or With somehelp cane) (exceptfortheuseofa Without help (Consider reablement buildingand (Consider reablement capacity opportunities) 14 of 21of

task? this with help anyone Does task? this with help anyone Does

No Yes No Yes No Yes No Yes No Yes No Yes Required Action Required Action Managing

No Yes No Yes No Yes No Yes No Yes No Yes everyday activities Assessor Notes: PersonalCare The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced (Consider reablement buildingand (Consider reablement capacity opportunities) 15 of 21of

Managing everyday activities theirgoals? become moreindependent or achieve thispersonto smallaids/gadgetstoassist Is theretheopportunity touse/demonstrate independent? thispersontobecomemore Would homemodifications,aidsandequipmentassist Aidsequipmentand tofindwords orfinishsentences) needsprompting useof interpretershere) aids.Donotindicate hearingaidsorspeech understood by others  rated Activity –Assessor Communication lastweek  rated Activity –Assessor them?  GP,Nurse,Continenceadvisor discussedwith anyone –e.g. Has theissues(s)been you managing? muchdoesthisbotheryouHow andhoware  problem? thinkmightbetheunderlying What doestheperson bowelorboth Identify whetherbladder, If yes, orpain? you concern,embarrassment Do your bowelsorbladderevercause particularlypeoplecontinence sensitivefollowing is aaskingas most issue to Be mindful whenthequestions Continence The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced

Prompt: Prompt: Prompt:

Communication (bowelsand/orbladder Continence

Assistance always required Assistance intent,or personoften misses thespeakers required(e.g.ifthe Some assistance as aidsandequipment such independentuseof required(including No assistance of incontinence) (nocontrolordaily episodes Incontinent onceperday) incontinence(lessthan Occasional orostomy. Ratebasedon ofcatheter continentincludingself-management Completely Do you ever have trouble getting to the toilet on time? getting trouble the to you haveever Do Most continence issues can be resolved, does the person know what services and resources areservices resources the and available issuescan know what to be does person Mostresolved, continence – need for assistance with understanding or making oneself ormaking oneself forassistancewith understanding –need 16 of 21of )

this task? help with anyone Does task? this with help anyone Does

No Yes

Yes No Yes No

No Yes No Yes Required Action Required Action Managing

Yes No No Yes everyday activities The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced 17 of 21of

Managing everyday activities Action required support? servicesor without additional sustainable Is thecarerelationship Assessorrated: planorcarearrangement inplace? Is thereanemergency  them withyour carerole? Do you haveotherrolesandresponsibilites? allowance? Do you receiveacarer role? community oranyotherorganisationsinyour care Do you havesupportfromfamily, friends, financialcircumstancesetc. socialconnections, emotionalhealth,familyrelationships, e.g. physicalhealth, affecting your healthandwellbeing? areyourHow careresponsibilities  itchangingovertime? Doyou well? haveanyconcerns?Is Is thecarerelationshipworking  Doyou feelconfidentinyour carerole? What type ofcaredoyou provide,howoften? responsibilities? your areyouHow managingwith care Carerhealth and wellbeing(to becompletedthe with carer) Carer name: carer(s)has (careapersonthe Fill recipient)information below outif Carerdetails Carerand health The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced role? careyourskills andthe knowledge carry out information feel sufficient and right to you Dohave you Prompt: Prompt: Prompt: wellbeing

What is not working well? What would you like to improve? Any concerns about isnotAnyconcerns Whatpersonal youyour safety? working well?like improve? to would What carer. Do you manage to get time for yourself? If health and wellbeing is compromised consider a separate assessment for separate wellbeingiscompromiseda health assessment for and consider yourself? If time you for manage get Do to Yes Gender: No e.g. employment, education, other care responibilities such as dependentchildren? careresponibilitiessuchas education,other e.g. employment, 18 of 21of

Birth: Date of

Yes

Don’t know Don’t know support without additional arrangements aresustainable carer Yes, down within months arrangements likely tobreak No, carer broken down havealready No, arrangements Organisation UR Number: Gender: Birth: Date of Name If yes consumer:  :

No Relationship to , what are they and how are you managing to balance areyou theyandhow managingtobalance are , what

/

/ / Yes

home? consumers 

Lives in Lives in No Notasked details Contact Or affixlabelhere

Carer Carer health health and and wellbeing wellbeing Care recipient(s) Fill informationtheout aboutpeople the client the is caring for Action required Is thecarerelationshipsustainable? planorcarearrangementinplace? Is thereanemergency role? Do youyour haveany helpwith care wellbeing? doesthisimpactonyourHow healthand own areyouHow managing?Whatisworkingwell,notwell? withadisabiliy?Are you caringforany person(s) for?(Completethetablebelow) manypeopledoyouHow providecare Care recipientisa carer Action required opportunuties withthecarer? areferraltocarersupportservice/counselling/social Does theprimary carerneed recipient? assessmentasa care Does thecarerneedan behaviouralchanges? managing issuessuchas or practicaltraining inlifting,managingmedicine,othertasks Does thecarerneed/want Ifso what aretheirpreferences? providing carefortherecipient. providersin service preferencesforworkinginpartnershipwith Does thecarerhave options? includingrespite informationabout availablesupportservices, Has thecarerbeengiven Careractions: Consider the carer’spriorities, and needs goalsand they discuss how canbeactioned. Assessorrated: The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Examplesare below Yes Yes Gender: No No 19 of 21of Birth: Date of / / /

/ / /

consumer: to Relationship

home? consumers Lives in Contact details

No Yes No Yes Not sure No Yes Not sure No Yes Not sure No Yes Not sure No Yes No Yes No Yes

Carer health and wellbeing Assessornotes/observations about needscarer the and the goals; needs goalsofand the recipient care The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced as a carer. 20 of 21of

Carer health and wellbeing Action required If yes concerns? ofsqualororhoardingotherphysical environment Is thereany evidence • • • refer to yes,toanyoftheabove If Homeless Insecure Unsafe At risk is: that Is thepersoninhousing/accommodation  Is thisworkingwellforyou?  Accommodation Accommodation The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Prompt: Prompt:

Can you tell me about your current accommodation? How long have you livedhere? meaboutyour currentaccommodation?Howlonghave Can you tell

Yes Yes Yes Yes For public (social) housing refer to the local housing officer refer tothelocalhousing For public(social)housing Specialist family violence servicee.g.Home atLast Homelessness support , specify and explore how these conditions impact on the person’s health andwellbeing. ontheperson’s health howtheseconditionsimpact , specifyandexplore and safety and

(e.g.

i.e. family violence, physical danger or threat physical dangeror i.e. family violence,

No No No No Consider any risks, hazards orany hazards neglectrisks, signs of Consider i.e. temporarily staying with friends and familyorothertemporary accommodation staying with friendsand i.e. temporarily eviction, behind in rent) eviction, behindin Notstated/unknown Notstated/unknown Notstated/unknown Notstated/unknown

Yes 

HACC MDSitem 21 No

of 21of Yes No Organisation UR Number: Gender: Birth: Date of Name Any concerns? :

/

/ /

Yes Or affixlabelhere

CarAerc hcoeamltmh od No aantido n and wellbseainfegty Action required and if they smoke bedin Note:are at People if risk they problems,higher mobilityifhave there are tendencies hoarding ahighsidedashtray). secondsmoke alarmand/or and may needa ofmore thanonesmokealarm Is thepersonatriskandinneed ? checkedinthe last12months Has thesmokealarmbeen no If inthehouse? Is thereaworkingsmokealarm  Note: emergency plans. If no, wave orflood? planincaseoffire,heat Do you haveapersonalemergency Personalemergency planning Action required Violence Order(AVO) services? e.g.Apprehended legalissuesthatmay affect Does thepersonhaveany LegalIssues on1300368821 –contactSeniorsRightsVictoria experiencingelderabuse For olderpeople Action required moreoften orboth? worse orhappening Is theabusebecoming abuseofForms elder take? What form doestheabuse Assessor rated: yesIf Would you liketodiscussthis? controlsorhurtsyou? who Have you feltafraidofsomeone Feeling safe The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced

Prompt: Prompt: , is the person aware that this is a legislative requirement inVictoria? thatthisisalegislativerequirement , isthepersonaware encourage people living in a high bushfire or other risk areas to develop personal orotherriskareastodevelop livinginahighbushfire encouragepeople , who is the person afraid of? , who isthepersonafraid HACC assessment services need to comply with the peopleemergencies Vulnerable with policy. inneed comply to the HACC assessment services How does the person manage in heatwave conditions, are they vulnerable? What actions to be done and by whom be bytodone they and to are actionsin vulnerable? What conditions, Howthe heatwave manage does person address the vulnerability. theaddress Yes Yes Yes : physical abuse, sexual abuse, financial abuse, social abuse, neglect abuse, abuse, abuse,abuse, financial social sexual physical . If yes No No No 22 , provide details , provide of 21of

(e.g. smokes inbed (e.g. smokes unknown unknown unknown Not asked Notasked Notasked unknown unknown

Not stated/ No Yes Not stated/ No Yes Not stated/ No Yes No sure No Yes Unknown/ No Yes Unknown/ No Yes

Not stated/ No Yes

CarAerc hcoeamltmh od aantido n and wellbseainfegty The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced 23 of 21of

CarAerc hcoeamltmh od aantido n and wellbseainfegty Assessment Assessment The Home & Community The Home Care & Program is jointly by fundedCommonwealththeand Victorian governments HACC assessment tool – Page HACC assessment tool 2015& Department HealthHuman theof Services, by Victorian Produced Summary

24 of 21of Organisation UR Number: Gender: Birth: Date of Name :

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Assessment Carer health Summary and wellbeing