Determination of Need Functional Assessment Instrument Instruction Manual | APS-5500-MANUAL

Definitions

There are a few terms used throughout the DON manual that require a definition.

Client: Persons who are undergoing an assessment for the particular program or agency by which you are employed.
Assessor: The person conducting the assessment.
Caregivers: Caregivers are individuals who provide informal physical, emotional and cognitive supports. They are usually unpaid family members or friends who provide care for the applicant.

Functional Assessment (ADLs/IADLs) Introduction

The Determination of Need Functional Assessment (DON) instrument was originally developed as part of a contract with the Illinois Department of Aging to provide it with the means for determining eligibility for community based services. As such there was a need for the DON to identify those factors that were the best predictors of need for care. Furthermore, there was a need for the instrument to be constructed in a fashion that would permit the state to set funding caps for different levels of impairment, but also allow for adjustment as a care-recipient’s care needs changed. Beginning in 1987 and concluding in 1989, a group of researchers at the Gerontology Center of the University of Illinois at Chicago, worked on developing such an instrument. The process involved in the DON’s development is well documented in a three volume final report to the Illinois Department on Aging (Paveza et al., 1989; Prohaska et al., 1989; Hagopian et al., 1990) and in two articles (Paveza et al., 1990a; Paveza et al., 1990b).

Since the DON was developed as part of a state contract the instrument resides in the public domain. The instrument described in this manual represents a modification for use by those wishing to solely assess functional impairment in persons with whom they are working, as well as refinements made to the interpretative process as use of this instrument has evolved over time. Nevertheless, since the original DON was developed under a public contract, this modified DON also resides in the public domain.

The Determination of Need (DON) defines the factors which help determine a person’s functional capacity and their unmet need for assistance in dealing with these impairments. The DON allows for independent assessment of both impairment in functioning on Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) and the need for assistance to compensate for these impairments.

The backbone of determining the level of need for care is whether a person can perform activities of daily living (ADL). Table 1 presents the list of ADL included in the DON under two headings: BASIC AND INSTRUMENTAL.

Basic Activities of Daily Living (BADL)	Instrumental Activities of Daily Living (IADL)
Eating	Managing Money
Bathing	Telephoning
Grooming	Preparing Meals
Dressing	Laundry
Transfer (In & Out of Bed/Chair)	Housework
Bowel/Bladder Continence	Outside Home
	Routine Health
	Special Health
	Being Alone

Basic Activities of Daily Living (BADL)

Instrumental Activities of Daily Living (IADL)

Eating

Managing Money

Bathing

Telephoning

Grooming

Preparing Meals

Dressing

Laundry

Transfer (In & Out of Bed/Chair)

Housework

Bowel/Bladder Continence

Outside Home

Routine Health

Special Health

Being Alone

Basic Activities of Daily Living (BADL) refer to those activities and behaviors that are the most fundamental self-care activities to perform and are an indication of whether the person can care for ones own physical needs.

Instrumental Activities of Daily Living (IADL) are the more complex activities associated with daily life. (They are applications of the Basic Activities of Daily Living.) Information regarding both BADL and IADL are essential to evaluating whether a person can live independently in the community.

Determination of Need (DON) Functional Assessment Instrument

The Determination of Need (DON) Functional Assessment is a unique measure of functional assessment in that it differentiates between impairment in functional capacity and the need for care around a particular functional capacity. Furthermore, it is an ordinal scale with clearly defined meanings for each level of impairment, each level of unmet need for care and each functional activity. Because of its ordinal nature, it permits quantification of scores so that changes in scores in subscales for BADLs and IADL’s and for Total Impairment represent actual changes in impairment, and changes in scores for unmet need for care in BADLs, IADLs and Total Unmet Need for Care represent actual changes in unmet need for care. Table 2 presents the instrument in reduced format, a copy of the actual instrument for use is included at the end of this manual.

Before discussing the specific definitions that describe the functional activities included in the DON and the definitions that specify each of the levels of impairment and unmet need for care, some general comments about the DON are provided to assist in the completion of the instrument.

THE "CASE COMMENTS" SPACE TO THE RIGHT OF COLUMN B IN THE FUNCTIONAL STATUS SECTION IS USED TO:

Note special reasons for impairment or unmet need.
Describe the type of service, caregiver support or assistive devices that decreases the client’s unmet need.
Record the primary caregivers' names or other pertinent information.

COLUMN RULES:

Use the following criteria to decide when to stop asking questions for a particular Functional Status item or when to skip column B.

Ask each FUNCTIONAL STATUS item, starting with Column A.
If Column A, "level of impairment”, is scored “0", score Column B “0".
If Column A is scored greater than “0", ask Column B.

Determination of Need Functional Assessment

Function	Level of Impairment	Unmet Need for Care	Case Comments: Identify resources, describe special needs and circumstances that should be taken into account when developing a care plan
1. Eating	0 1 2 3	0 1 2 3
2. Bathing	0 1 2 3	0 1 2 3
3. Grooming	0 1 2 3	0 1 2 3
4. Dressing	0 1 2 3	0 1 2 3
5. Transferring	0 1 2 3	0 1 2 3
6. Continence	0 1 2 3	0 1 2 3
7. Managing Money	0 1 2 3	0 1 2 3
8. Telephoning	0 1 2 3	0 1 2 3
9. Preparing Meals	0 1 2 3	0 1 2 3
10. Laundry	0 1 2 3	0 1 2 3
11. Housework	0 1 2 3	0 1 2 3
12. Outside Home	0 1 2 3	0 1 2 3
13. Routine Health	0 1 2 3	0 1 2 3
14. Special Health	0 1 2 3	0 1 2 3
15. Being Alone	0 1 2 3	0 1 2 3
Box A: Subtotal Col A, Items 1-6	Box A	Box B	Box B: Subtotal Col B, Items 1-6
Box C: Subtotal Col A., Items 7-15	Box C	Box D	Box D: Subtotal Col B, Items 7-15
Box E: Subtotal Box A & Box C	Box E	Box F	Box F: Subtotal Box B & Box D
		Box G	Box G: Subtotal Box E & Box F

Column A: Level of Impairment

Each one of the basic and instrumental activities of daily living (BADL/IADL) needs to be discussed in terms of level of impairment. How the assessor mentions functional impairment is not as important as encouraging the client to report difficulties with the activity. Sample questions could include:

Are you able to do . . . ?
How much difficulty do you have in doing . . . ?

The object is to gather sufficient information to determine the most appropriate score below.

Score 0 - Performs or can perform all essential components of the activity, with or without an assistive device, such that:

no significant impairment of function remains; or
activity is not required by the client (IADLs: medication management, routine and special health only); or
client may benefit from but does not require verbal or physical assistance.

Score 1 - Performs or can perform most essential components of the activity with or without an assistive device, but some impairment of function remains such that client requires some verbal or physical assistance in some or all components of the activity.

This includes clients who:

experience minor, intermittent fatigue in performing the activity; or
take longer than would be required for an unimpaired person to complete the activity; or
must perform the activity more often than an unimpaired person; or
require some verbal prompting to complete the task.

Score 2 - Cannot perform most of the essential components of the activity, even with an assistive device, and/or requires a great deal of verbal or physical assistance to accomplish the activity.

This includes clients who:

experience frequent fatigue or minor exertion in performing the activity; or
take an excessive amount of time to perform the activity; or
must perform the activity much more frequently than an unimpaired person; or
require frequent verbal prompting to complete the task.

Score 3 - Cannot perform the activity and requires someone else to perform the task, although client may be able to assist in small ways; or requires constant verbal or physical assistance.

Column B: Unmet Need for Care

In scoring this column, the idea is both to obtain information from the client about their perceptions regarding need for care and to use your observational skills to determine what the impact might be on the client should care or assistance not be provided to the client. The availability of an appropriate caregiver also needs to be assessed.

Questions that might be asked of clients and caregivers are:
Can you tell me if you are getting enough help in meeting your needs around _? Do you think you need more help with _?

In your own observations, look at client’s mobility, level of clutter, appearance, unpaid bills, forgetfulness, etc., to assess the level of risk to health or safety if current levels of assistance are not maintained, or if additional assistance is not added.

Score 0 - The client’s need for assistance is met to the extent that the client is at no risk to health or safety if additional assistance is not acquired; or the client has no need for assistance; or additional assistance will not benefit the client.

Score 1 - The client’s need for assistance is met most of the time, or there is minimal risk to the health and safety of the client if additional assistance is not acquired.

Score 2 - The client’s need for assistance is not met most of the time; or there is moderate risk to the health and safety of the client if additional assistance is not acquired.

Score 3 - The client’s need for assistance is seldom or never met; or there is severe risk to the health and safety of the client that would require acute medical intervention if additional assistance is not acquired.

Item Definitions

EATING
1. Is the client able to feed himself/herself?
  
  Assess the client’s ability to feed oneself a meal using routine or adapted table utensils and without frequent spills. Include the client’s ability to chew, swallow, cut food into manageable size pieces, and to chew and swallow hot and cold foods/beverages. When a special diet is needed, do not consider the preparation of the special diet when scoring this item (see “preparing meals” and “routine health” items).
2. Is someone available to assist the client at mealtime?
  
  If the client scores at least one (1) in Column A, evaluate whether someone (including telephone reassurance) is available to assist or motivate the client in eating.
BATHING
1. Is the client able to shower or bathe or take sponge baths for the purpose of maintaining adequate hygiene as needed for the client’s circumstances?
  
  Assess the client’s ability to shower or bathe or take sponge baths for the purpose of maintaining adequate hygiene. Consider minimum hygiene standards, medical prescription, or health related considerations such as incontinence, skin ulcer, lesions, and frequent profuse nose bleeds. Consider ability to get in and out of the tub or shower, to turn faucets, regulate water temperature, wash and dry fully. Include douches if required by impairment.
2. Is someone available to assist or supervise the client in bathing?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of resources to assist in bathing. If intimate assistance is available but inappropriate and/or opposed by the client, consider the assistance unavailable.
GROOMING
1. Is the client able to take care of his/her personal appearance?
  
  Assess client’s ability to take care of personal appearance, grooming, and hygiene activities. Only consider shaving, nail care, hair care, and dental hygiene.
2. Is someone available to assist the client in personal grooming tasks?
  
  If the client scores at least one (1) in Column A, evaluate the continued personal assistance needed, including health professionals, to assist the client in grooming.
DRESSING
1. Is the client able to dress and undress as necessary to carry out other activities of daily living?
  
  Assess the client’s ability to dress and undress as necessary to carry out the client’s activities of daily living in terms of appropriate dress for weather or street attire as needed. Also include ability to put on prostheses or assistive devices. Consider fine motor coordination for buttons and zippers, and strength for undergarments or winter coat. Do not include style or color coordination.
2. Is someone available to assist the client in dressing and undressing?
  
  If the client scores at least one (1) in Column A, evaluate whether someone is available to help dressing and/or undressing the client at the times needed by the client. If intimate assistance is available but inappropriate and/or opposed by the client, consider the assistance unavailable.
TRANSFER
1. Is the client able to get into and out of bed or other usual sleeping place?
  
  Assess the client’s ability to get into and out of bed or other usual sleeping place, including pallet or arm chair. Include the ability to reach assistive devices and appliances necessary to ambulate, and the ability to transfer (from/to) between bed and wheelchair, walker, etc. Include ability to adjust the bed or place/remove handrails, if applicable and necessary. When scoring, do not consider putting on prostheses or assistive devices.
2. Is someone available to assist or motivate the client to get in and out of bed?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of resources, (including telephone reassurance and friendly visiting) to assist or motivate the client in getting into and out of bed.
CONTINENCE
1. Is the client able to take care of bladder/bowel functions without difficulty?
  
  Assess the client’s ability to take care of bladder/bowel functions by reaching the bathroom or other appropriate facility in a timely manner. Consider the need for reminders.
2. Is someone available to assist the client in performing bladder/bowel functions?
  
  If the client scores at least one (1) in Column A, evaluate whether someone is available to assist or remind the client as needed in bladder/bowel functions.
MANAGING MONEY
1. Is the client able to handle money and pay bills?
  
  Assess the client’s ability to handle money and pay bills. Include ability to plan, budget, write checks or money orders, exchange currency, and handle paper work and coins. Include the ability to read, write and count sufficiently to perform the activity. Do not increase the score based on insufficient funds.
2. Is someone available to help the client with money management and money transactions?
  
  If the client scores at least one (1) in Column A, evaluate whether an appropriate person is available to plan and budget or make deposits and payments on behalf of the client. Consider automatic deposits, banking by mail, etc.
TELEPHONING
1. Is the client able to use the telephone to communicate essential needs?
  
  Assess the client’s ability to use a telephone to communicate essential needs. The client must be able to use the phone: answer, dial, articulate and comprehend. If the client uses special adaptive telephone equipment, score the client based on the ability to perform this activity with that equipment. Do not consider the absence of a telephone in the client’s home. (Note: The use of an emergency response system device should not be considered)
2. Is someone available to assist the client with telephone use?
  
  If the client scores at least one (1) in Column A, evaluate whether someone is available to help the client reach and use the telephone or whether someone is available to use the telephone on behalf of the client. Consider the reliability and the availability of neighbors to accept essential routine calls and to call authorities in an emergency.
PREPARING MEALS
1. Is the client able to prepare hot and,/or cold meals that are nutritionally balanced or therapeutic, as necessary, which the client can eat?
  
  Assess the client’s ability to plan and prepare routine hot and/or cold, nutritionally balanced meals. Include ability to prepare foodstuffs, to open containers, to use kitchen appliances, and to clean up after the meal, including washing, drying and storing dishes and other utensils used in meal preparation. Do not consider the ability to plan therapeutic or prescribed meals.
2. Is someone available to prepare meals as needed by the client?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of resources (including restaurants and home-delivered meals) to prepare meals or supervise meal preparation for the Client. Consider whether the resources can be called upon to prepare meals in advance for reheating later.
LAUNDRY
1. Is the client able to do his,/her laundry?
  
  Assess the client’s ability to do laundry including sorting, carrying, loading, unloading, folding, and putting away. Include use of coins where needed and use of machines and/or sinks. Do not consider the location of the laundry facilities.
2. Is someone available to assist with performing or supervising the laundry needs of the client?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of laundry assistance, including washing and/or dry cleaning. If public laundries are used, consider the reliability of others to insert coins, transfer loads, etc.
HOUSEWORK
1. Is the client able to do routine housework?
  
  Assess the client’s ability to do routine housework. Include sweeping, scrubbing, and vacuuming floors. Include dusting, cleaning up spills, and cleaning sinks, toilets, bathtubs. Minimum hygienic conditions for client’s health and safety are required. Do not include laundry, washing or drying dishes or the refusal to do tasks if refusal is unrelated to the impairment.
2. Is someone available to supervise, assist with, or perform routine household tasks for the client as needed to meet minimum health and hygiene standards?
  
  If the client scores at least a one (1) in Column A, evaluate the continued availability of resources, including private pay household assistance and family available to maintain the client’s living space. When the client lives with others, do not assume the others will clean up for the client. This item measures only those needs related to maintaining the client’s living space and is not to measure the maintenance needs of living space occupied by others in the same residence.
OUTSIDE HOME
1. Is the client able to get out of his/her home and to essential places outside the home?
  
  Assess the client’s ability to get to and from essential places outside the home. Essential places may include bank, post office, mail box, medical offices, stores, and laundry if nearest available facilities are outside the home. Consider ability to negotiate stairs, streets, porches, sidewalks, entrance and exits of residence, vehicle, and destination in all types of weather. Consider the ability to secure appropriate and available transportation and to know locations of home and essential places. Lack of appropriate and available transportation as needed, will increase the score. However, in scoring, do not consider the inability to afford public transportation.
2. Is someone available to assist the client in reaching needed destinations?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of escort and transportation, or someone to go out on behalf of the client. Consider banking by mail, delivery services, changing laundromats, etc., to make destinations more accessible.
ROUTINE HEALTH CARE
1. Is the client able to follow the directions of physicians, nurses or therapists, as needed for routine health care?
  
  Assess the client’s ability to follow directions from a physician, nurse or therapist, and to manipulate equipment in the performance of routine health care. Include simple dressings, special diet planning, monitoring of symptoms and vital signs (e.g. blood pressure, pulse, temperature and weight), routine medications, routine posturing and exercise not requiring services or supervision of a physical therapist.
2. Is someone available to carry out or supervise routine medical directions of the client’s physician or other health care professionals?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of someone to remind, supervise or assist the client in complying with routine medical directions. If the assistance needed involves intimate care, and the caregiver is inappropriate and/or opposed by the client, consider the assistance unavailable.
SPECIAL HEALTH CARE
1. Is the client able to follow directions of physicians, nurses or therapists as needed for specialized health care?
  
  Assess the client’s ability to perform or assist in the performance of specialized health care tasks which are prescribed and generally performed by licensed personnel including physicians, nurses, and therapists. Include blood chemistry and urinalysis; complex catheter and ostomy care; complex or non-routine posturing/suctioning; tube feeding; complex dressings and decubitus care; physical, occupational and speech therapy; intravenous care; respiratory therapy; or other prescribed health care provided by a licensed professional. Score "O" for clients who have no specialized health care needs.
2. Is someone available to assist with or provide specialized health care for the client?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of specially trained resources as necessary to assist with or perform the specialized health care task required by the client.
BEING ALONE
1. Can the client be left alone?
  
  Assess the client’s ability to be left alone and to recognize, avoid, and respond to danger and/or emergencies. Include the client’s ability to evacuate the premises or alert others to the Client’s need for assistance, if applicable, and to use appropriate judgment regarding personal health and safety.
2. Is someone available to assist or supervise the client when the client cannot be left alone?
  
  If the client scores at least one (1) in Column A, evaluate the continued availability of someone to assist or supervise the client as needed to avoid danger and respond to emergencies. Consider friendly visiting, telephone reassurance, and neighborhood watch programs.

Scoring The Don

Scoring the DON is done by obtaining a series of totals in boxes A, B, C, D, E, F, and G on the bottom of the DON form.

SUBTOTALS OF COLUMNS A AND B:

Add the scores for the first six functional activities (1-6) of Column A, and enter that score in Box A (SUM [1 - 6] = Box A). Then add the scores for the last nine functional activities (7-15) and enter that score in Box C (SUM [7 - 15] = Box C). Finally add the scores for Box A and Box C and place that total in Box E (Box A + Box C = Box E).
Add the scores for the first six functional activities (1-6) of Column B, and enter that score in Box B (SUM [1 - 6] = Box B). Then add the scores for the last nine functional activities (7-15) of Column B and enter that score in Box D (SUM [7 - 15] = Box D). Finally add the scores for Box B and Box D and place that total in Box F (Box B + Box D = Box F)
Add the scores from Box E and Box F and enter that total in Box G (Box E + Box F = Box G).

Each of these boxes provides specific information about the client. Box A provides a score that represents total impairment in Basic Activities of Daily Living, while Box C provides a score that represents total impairment in Instrumental Activities of Daily Living. Box E provides a summary score that represents total functional impairment.

Box B provides a score that represents the total unmet need for care in Basic Activities of Daily Living, while Box D provides information about the total unmet need for care around Instrumental Activities of Daily Living. Box F provides a summary score of unmet need for all Activities of Daily Living.

Box G provides a summary score that represents a total care burden and represents both a combination of total impairment and total unmet need for care.

Interpretation of The Don

Interpretation of the DON should be considered in light of several factors including the degree to which scores are a mix between no impairment and moderate and severe impairment. However, by dividing the score entered in any Box by the number of activities that make up its subscale score, it is possible to reduce that score to an ordinal equivalent, a category between No Impairment and Severe Impairment. To derive standardized scores for each box: Divide Box A and Box B by 6; Divide Box C and Box D by 9; Divide Box E and Box F by 15; and divide Box G by 30. This will provide you with a score between 0 and 3, which can then be matched to the interpretations offered below for the standardized scores. Remember that to use these interpretations you must divide the score in any box by the numbers noted above (6,9,15 or 30).

Score Interpretation

0: No impairment or no unmet need for care
Greater than 0 and less than or equal to 1: Mild impairment or mild unmet need for care
Greater than 1 and less than or equal to 1.5: Mild to Moderate impairment or mild to moderate unmet need for care
Greater than 1.5 and less than or equal to 2: Moderate impairment or moderate unmet need for care
Greater than 2 and less than or equal to 2.5: Moderate to severe impairment or unmet need for care
Greater than 2.5: Severe impairment or unmet need for care

To make a specific interpretation, choose one of the boxes and divide that score by the appropriate number as indicated on page 14. Then interpret that modified score based on the functional activities or unmet need for care represented by that box. For example if discussing the modified Box A score, a score of 1.7 would be interpreted to mean that the client has mild to moderate impairment in Basic Activities of Daily Living, while this same score for box C would be interpreted to mean mild to moderate impairment in Instrumental Activities of Daily Living. In Box D, it would be interpreted to mean mild to moderate unmet need for care. Finally in Box G this score would be interpreted to mean mild to moderate overall care burden in functional activities.

Reporting can than be enhanced by noting the specific areas of impairment. Thus one might report that: “Mrs. Jones is moderately impaired in BADL’s with specific impairments in Bathing, Dressing and Transfer. She has a moderate unmet need for care in BADL’s with specific needs in Bathing and Transfer.” Similar specificity can be applied to IADL’s, total functional capacity and total care burden.

References

Hagopian M, Paveza GJ, Prohaska T, Cohen D: Determination of Need - Revision Final Report, Volume III. Chicago, Illinois: University of Illinois at Chicago, 1990.

Paveza GJ, Cohen D, Hagopian M, Prohaska T, Blaser CJ, Brauner D: A Brief Assessment Tool for Determining Eligibility and Need for Community Based Long Term Care Services. Behavior, Health and Aging 1: 121-132, 1990a.

Paveza GJ, Cohen D, Blaser CJ, Hagopian M: A Brief Form of the Mini-Mental State Examination for Use in Community Settings. Behavior, Health and Aging 1: 133-139, 1990b.

Paveza GJ, Prohaska T, Hagopian M, Cohen D: Determination of Need - Revision: Final Report, Volume I. Chicago, Illinois: University of Illinois at Chicago, 1989.

Prohaska T, Hagopian M, Cohen D, Paveza GJ: Determination of Need - Revision Final Report, Volume II. Chicago, Illinois: University of Illinois at Chicago, 1989.