Module #4: Community Living Skills

Contents

4.1 "Need for Assistance" Defined
4.2 Help Is Needed Due to Mental Illness or Substance Use Disorder
4.3 Frequency of Help Needed
4.4 Ranking Fluctuating Needs
4.5 Discharge Imminent
SPECIFIC COMMUNITY LIVING SKILLS
4.6 Benefits/Resource Management
4.7 Basic Safety
4.8 Social or Interpersonal Skills
4.9 Home Hazards
4.10 Money Management
4.11 Basic Nutrition
4.12 General Health Maintenance
4.13 Managing Psychiatric Symptoms
4.14 Hygiene and Grooming
4.15 Taking Medications
4.16 Monitoring Medication Effects
4.17 Monitoring Meds and/or Managing Symptoms
4.18 Transportation
4.19 Physical Assistance

4.1 "Need for Assistance" Defined

Each skill or activity on the MH/AODA FS was developed from BRC and CSP language. Each skill has its own definition purposefully constructed for the MH/AODA FS. Screeners are to follow the definitions precisely in order to select the most accurate rating for level of help needed.

Eligibility for programs and services is based on an applicant's need for assistance.

"Need for assistance" is broadly defined to include any kind of support from another person (monitoring, supervising, reminders, verbal cueing, or hands-on assistance) needed because of a mental health and/or substance use disorder.

Because it is "support from another person," it does not include self-help, medication, money, or equipment.

Do not check assistance needed if the assistance is due only to cultural or language differences.

Do not check help needed for money management and basic nutrition if all the person needs is transportation to the bank or stores. The transportation issue would be captured in the transportation question.

Always select the answer that most closely describes the person's need for help from another person - whether they are actually getting that help or not. Always select ONLY ONE rating of help needed with each activity.

Indicate the amount of help the person needs from another person - no matter who is providing the help, and no matter where. (The only exception to this is that when a person is about to be discharged from a facility within a few days, estimate what they'll need in their new setting.)

In the MH/AODA FS, "basic" means adequate for health and safety. "Needs" and "safety" should not be over-interpreted. The MH/AODA FS is intended to be an objective screen of people's need for assistance. Thus, you should ask yourself, 'Would another screener of another discipline, program, gender, culture, etc., rank the person the same way?" (See "2.12 Ensuring Inter-Rater Reliability.")

If a person can complete a task independently, but it takes them a very long time, you need to consider if the person needs any help with that task to complete it safely and without negative outcomes. If they are in fact completing tasks safely, it does not matter if it takes two or three times longer than for most people. However, if there were significant hardship or negative outcomes for that consumer doing the task so slowly, than it would be justified to mark the person as needing help.

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4.2 Help Is Needed Due to Mental Illness or Substance Use Disorder

If the person needs help due to a physical impairment (from a disability or infirmities of aging), do not check Community Living Skills in the MH/AODA FS. Such needs are to be indicated only in the last item in this module, "Physical Assistance."

When someone has dementia co-occurring with mental illness and/or substance abuse, of course it is difficult if not impossible to separate the reasons for their functional impairments. For such individuals, mark help needed in Community Living Skills on the MH/AODA FS. If the person has mental illness and/or substance abuse as well, they could be eligible for long-term care and MH/AODA programs. If a person has only dementia, they should be referred for a LTC FS.

Examples:

• Mick has quadriplegia and major depression. In Community Living Skills in the MH/AODA FS, you only indicate help Mick needs because of his depression. Under the last item, "Physical Assistance," you check tasks Mick needs help with because of his quadriplegia (e.g., bathing, dressing, mobility, transfers, meds, money, and transportation). In fact, Mick doesn't need much help with any of the Community Living Skills because of his depression. He's not eligible for MH programs.
  
  
• Jose has quadriplegia and schizophreniform disorder. In Community Living Skills in the MH/AODA FS, you only indicate help Jose needs because of his mental illness. Under the last item, "Physical Assistance," you check tasks Jose needs help with because of his quadriplegia (e.g., bathing, dressing, mobility, transfers, meds, money, and transportation). In Community Living Skills Jose does need help with "Social/Interpersonal Skills" and "Managing Psychiatric Symptoms" due to his mental illness. He'd need this support even if he didn't also have a physical disability.
  
  
• Martha is a frail 67-year-old with residual schizophrenia, dementia, history of alcohol abuse, congestive heart failure and history of a stroke. She likes to keep herself very clean, and needs physical help getting in and out of the bathtub. You’d mark her Independent in "Hygiene and Grooming" (because her schizophrenia does not make her need help with this), and you'd check "Bathing" under the "Physical Assistance" item.
  
  
• George is a 62-year-old long-time alcoholic diagnosed with schizotypal personality disorder, organic brain syndrome and "alcoholic dementia." His cognition, self-care, and functioning are poor. It's not clear (even to his psychiatrist) whether his impairments are due to dementia, organic brain disease, or mental illness. It doesn't matter: You check all the Community Living Skills with which he needs help.

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4.3 Frequency of Help Needed

The frequencies for help needed should provide general indications of high frequency versus low frequency. Most screen items have frequency choices, for example, of "Independent," "Less than monthly," "1 to 4 times a month," and "More than one time per week."

We know that selecting a frequency is difficult because:

• You might not know in advance what an applicant will actually need, especially if you just met them, and
• People's needs often vary, especially due to the cyclical nature of mental illness.

On the other hand, you have always estimated the frequency of help needed, to decide your initial service plan and when to revisit the person. The MH/AODA FS just asks for that same professional judgment.

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4.4 Ranking Fluctuating Needs

This section purposefully repeats Section 2.18.

Mental illnesses are often cyclical, with varying levels of symptoms and functioning. The MH/AODA FS is a mix of a "snapshot" view - the person's current status now and over the past few weeks - and an historical (or "movie") view looking over the past few months up to the past year or two. Every day MH/AODA practitioners (and consumers) make judgments based on this mix of snapshot and historical views, to determine the frequency of contacts and of help needed now and for the next few weeks or months. Of course people's needs will change, and of course predictions are only approximate, but they reflect expert judgment (and sometimes research data) of the frequency of interventions needed to promote recovery and prevent crises.

The MH/AODA FS is similar. For some "Community Living Skills," you are asked to indicate the approximate frequency at which help is needed. To make it easier to select answers, the answer choices have been reduced to "Independent," "Less than monthly," "1 to 4 times a month," "More than one time a week."

Less than monthly
Check this for applicant who, for example:

• Sees their case manager only every few months and is otherwise independent.
• Has had two or three episodes over the past year, requiring interventions for 1 or 2 weeks each episode - such that it averages out to less than monthly; and the episodes are unpredictable such that regular and more frequent assistance would not prevent the episodes.
• Recently became independent with a skill, but still needs some follow up and back up.

1 to 4 times a month
Check this for applicant who, for example:

• Needs help with budgeting and finances just 1 to 4 times a month.
• Needs help every other week, for instance, with housekeeping or grocery shopping.
• Needs med boxes filled every two weeks (filling two weekly med boxes at once).
• Is still developing skills they learn during visits with their case manager every two weeks.
• Has crises if they don't get regular emotional support and reinforcement 2 or 3 times a month.
• Does pretty well most of the time, but sometimes calls their case manager for support; this happens irregularly, but on average over the past six months or so, it's about 1 to 4 times a month.
• Does not recognize when symptoms escalate, and they do so within 2 or 3 weeks; person needs someone every two weeks to monitor symptoms and prevent crises. For example, Stu has had crises from manic episodes 2 to 3 times a year. His mania progresses rapidly, within 2 or 3 weeks, and he doesn't see it starting. He needs someone to check in with him every two weeks to monitor for mania and help him prevent its escalation.

More than one time per week
Check this for applicant who, for example:

• Needs someone to give them their meds (psych and others) every day or more often.
• Forgets to take their meds unless the person's daughter calls to remind them every day to take them.
• Needs intensive case management and/or psych nursing visits 3 to 5 times a week.
• Comes in to the clinic every morning for meds and money.
• Does not recognize when symptoms escalate, and they do so within a day or two; person needs someone every two days to monitor symptoms and prevent crises. For example, Marilyn has schizophrenia and lives alone. Her MH case manager continues to see her three times a week to help her cope with her symptoms. With this support, Marilyn has only been hospitalized twice in the past three years.

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4.5 Discharge Imminent

If the person is now in a hospital or nursing home, and will go home in the next few days, record the help they'd need at home. Talk to the discharge planner, family, person, PT, OT, etc., to get the most accurate possible picture.

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Specific Community Living Skills

Each community living skill or activity has its own definition, which serves as the primary guide for screeners. The following section adds some additional instructions and some examples of when the definition does or does not apply. These examples are not exhaustive or all-inclusive; they only supplement the definitions.

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4.6 Benefits/Resource Management

Needs assistance to plan for, access, and navigate benefits (e.g., Section 8, SSI, SSDI, Medicaid, Medicare, insurance, etc.). Does NOT include money management, which is captured elsewhere.

This is included because it is often an important part of what MH/AODA practitioners provide.

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4.7 Basic Safety

Needs help from others because is unable to recognize immediately dangerous situations or to respond in an emergency. Does not include high-risk behaviors commonly engaged in by the public (such as unsafe sex, drinking and driving, poor health habits).

Assessments of safety can be very subjective and vary among individual screeners. Yet sometimes it is quite clear that safety is a problem, and this item is included on the MH/AODA FS to allow you to indicate those instances. As always, ask yourself, "Would other screeners, given the same observations and information, check this box?"

"Needs help from others" means that if the applicant does not get such help, bad things have happened or are very likely to happen. If the person has in fact been doing something completely independently without any risk or harm, then it would not appear that they need help from others.

This item was intended to focus narrowly on applicants who need help from others due to cognitive impairments caused by mental illness or substance abuse. It was not intended to include every risky or unhealthy choice people make. Especially when AODA is involved, our society is profoundly ambiguous about "choice" versus "disease." For the MH/AODA FS, consider the person's cognitive functioning when not drunk or on drugs. So, for instance, if someone drives drunk, they may suffer from the disease of alcoholism and need treatment (help from others), but they could have made advance arrangements (before getting drunk) to prevent themselves from driving drunk. In this way, the specific behavior of drunk driving is an informed choice and you would not mark this safety item for that individual. You would indicate substance abuse items elsewhere in the MH/AODA FS.

Check this for an applicant who, for example:

• Has no awareness of safety (e.g., wanders into traffic, wanders naked in winter).
• Is cognitively unable to respond to a crisis, for example, by calling 911 or running to neighbor's.
• Is unable to recognize and get out of threatening situations.

Do NOT check this for applicant who:

• Understands safety issues and knows how to call for help, but chooses to engage in risky behaviors (e.g., unsafe sex, drunk driving).
• Lives in a crime-ridden neighborhood, but understands risks and how to get help.
• Has a "Lifeline" (personal emergency response button) and knows when and how to use it.
• Might cause some safety concerns for other adults, for instance, by distracting drivers with bizarre behaviors on the sidewalk.
• Who is doing something that might cause safety concerns, but no more than normal life risks (e.g., the risk of getting in a car accident on the way to work). (In other words, don't exaggerate "what ifs" that aren't really likely to occur, and remember to consider inter-rater reliability based on facts.)

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4.8 Social or Interpersonal Skills

Needs assistance to effectively interact with others to have adult social relationships, or to plan for and carry out adult social or recreational activities according to personal preferences.

This is obviously more of a judgment question than many other items on the MH/AODA FS. But it's an important issue to include. In the majority of cases, most screeners would agree on whether this is an issue for someone.

Check this for applicant who, for example:

• Has become isolated and never leaves his or her apartment.
• Needs someone to accompany them in public and help interact with others.
• Has no friends, no hobbies, and will not leave their bedroom.
• Has agoraphobia and needs assistance to recover and make some trips out.

Do NOT check this for applicant who:

• Enjoys a lot of time alone, but does have a few supportive friends and can interact in public.
• Suffers some social prejudices (e.g., reactions to unusual appearance or mannerisms) but is able to interact effectively with strangers.
• Just needs transportation to get out more, but can interact and socialize.

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4.9 Home Hazards

Needs assistance to maintain basic living environment to avoid disease hazards, fire hazards (e.g. hoarding), and/or odors noticeable from outside.

This item is basically looking for housekeeping adequate to avoid disease or danger. Even if the person's housekeeping has declined, say due to depression, do not check this item unless it has declined to the point of creating immediate dangers or health hazards.

Check this for applicant whose:

• Apartment has garbage strewn throughout, with mice feces on many surfaces.
• Home has feces or urine throughout the rooms.
• Home is piled high with boxes, newspapers, magazines, with only narrow pathways through the rooms (i.e., "hoarding").
• Person is at risk of hypothermia because home or heating is inadequate.
• Building is structurally unsound, with high likelihood of collapsing.
• House has immediate fire hazards, e.g., loose or burned electrical wires, gas leaks, etc.

Do NOT check this for applicant whose:

• Home is messy (like a teen's bedroom, a bachelor's pad, a messy co-worker's place) but there are no immediate risks of disease.
• House has some mice, but no mouse feces or odor in living areas.
• Dishes are often left unwashed for several days at a time.
• Toilet bowl is brown inside but toilet functions.
• Home is heated with a wood stove and has an outhouse and has no running water.
• Cat litter stinks, but there is no feces or urine outside the box.
• Housekeeping has deteriorated due to mental illness, but is good enough to avoid dangers or health hazards.

Note: Many times if these problems are present, neighbors may complain and/or landlords may threaten eviction. However, since behaviors of neighbors and landlords can be arbitrary, the definition is based on condition of the home, not the presence of complaints or eviction threats.

Also consider inter-rater reliability (see Instructions 2.12). Housekeeping standards vary widely among individuals, including screeners. So even though a screener finds a household far below what they consider acceptable standards, the screener should apply the criteria listed above and mark the person independent if none apply.

MH/AODA screeners may be mandatory reporters for child abuse and neglect. If you see poor housekeeping creating risk factors to young children, such as access to garbage, you should respond appropriately. This item looks for immediate dangers and health hazards which exist for the applicant (and would thus exist for any children in the home as well). The functional screen does not, however, look for lax parenting or risks resulting from young children's inability to recognize dangers present in the home.

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4.10 Money Management

Needs assistance to manage finances for basic necessities (food, clothing, shelter). Includes needing assistance to handle money, pay bills, and to budget.

Do not check this if the limitation is due to cultural issues (e.g., recent immigrant who has not learned U.S. currency and/or English language). If a person's inability to manage money is due solely to a language barrier and not due to a cognitive or physical disability or mental illness, the person should be considered independent for purposes of the MH/AODA FS.

Check this for applicant who:

• Has a rep payee because applicant is not able to manage own finances at this time.
• Has cognitive impairments making them unable to do cash transactions and/or to pay bills or budget.
• Does not recognize manic episodes, and spends exorbitantly during them.
• Spends all money on addictions and unable to pay rent, groceries, etc.

Do NOT check this for applicant who:

• Is actually able to manage money, but has a rep payee due to local policy or court order, or for convenience (e.g., to avoid costs of money orders).
• Needs AODA treatment but is able to manage money enough to meet basic needs of food, shelter, and clothing.
• Recently came to U.S. and has not yet learned U.S. currency and English language, so requires help with finances due to that.
• Is able to manage own money, pay bills, and budget finances, but needs help with transportation to the bank and to the mailbox. (The person would be marked independent with money management, and the transportation item would be checked.)
• Is 17 years old, is able to use cash, has cognitive/emotional ability to start managing money, but has not yet had a checking account or a need to budget or pay bills. (This should not count toward eligibility for MH programs.)

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4.11 Basic Nutrition

Needs assistance to maintain eating schedule, obtain groceries, and/or to prepare or obtain "routine" meals (and avoid spoiled foods). Does NOT include transportation, which is captured elsewhere.

Note: "Routine" in this definition was intended to mean "average," not regularly scheduled. The functional screen will be revised to change "routine" to "simple," because the person does not need to be able to bake a full-course meal; they only need to be able to make simple meals such as a sandwich, cereal, and something heated on stovetop or in microwave.

Check this for applicant who:

• Receives "meals on wheels" because they otherwise would not get adequate nutrition.
• Due to cognitive/emotional issues, needs someone to help with grocery shopping every week or so (not just transportation).
• Seems unable to distinguish spoiled from fresh foods and has spoiled food in kitchen; case manager has to come clean it out or person will eat it and get sick.
• Has diagnosis of anorexia or bulimia and currently requires interventions from family and/or providers to ensure basic nutrition.
• Has mental illness and/or substance use disorder severe enough to be compromising the person's basic nutrition, i.e., causing malnutrition.
• Due to MH/AODA conditions and/or cognitive impairments, is not able to make informed choices about food enough to have basic nutrition.

Do NOT check this for applicant who:

• Makes informed choices to eat mostly junk food, but does understand and is capable of getting adequate nutrition.
  • Note: Case managers differ in the judgment of when a consumer needs them to grocery shop to avoid junk food. This will need to be clarified as the MH/AODA FS is further developed.
• Doesn't cook much, but can prepare cold meals (cereal, sandwiches) and can use microwave.
• Eats meals at unusual times.
• Can cook and select groceries but needs rides to the grocery store.
• Is not following a recommended diet, including diabetes diet, weight-loss diet, low cholesterol, low salt, etc. (Instead, check "general health maintenance" if, e.g., diabetes is out of control. This question is basic nutrition only.)
• Has spoiled food in 'fridge and kitchen, but does not eat it.
• Needs transportation to and from the grocery store, but can shop.
• Has agoraphobia and orders groceries on-line for home delivery.
• Needs help due to a physical disability, not MH/AODA (See Instructions 4.2).

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4.12 General Health Maintenance

Needs assistance to care for own health and to recognize symptoms. Includes managing health conditions (e.g., diabetes, hypertension) and making and keeping medical appointments. Does NOT include medication management, which is captured elsewhere. Also does not include transportation, if person arranges it herself.

The person needs help from others because they are unable to self-manage current health conditions or health risks. "Unable to self-manage" means the person:

• Is unable to recognize problems;
• Is unable to respond to problems;
• Does not know contributing factors and corrective actions; OR
• Has a history of failure to self-manage health resulting in multiple ER visits or hospitalizations (inpatient or out-patient).

Check this for applicant who:

• Is unable to make and/or keep healthcare appointments (because of cognitive/emotional impairments including AODA).
• Is not able to notice health problems and/or to respond to them appropriately, e.g., by calling her nurse or doctor.
• Needs family or staff to monitor health symptoms, as applicant is unable to do so.
• Because of schizophrenia, is unable to manage diabetes.
• Has been in the ER and hospital several times from health crises caused by failing to manage health problems. Examples: diabetic coma, or GI bleed (gastrointestinal bleed) in alcoholic. (Does not include health problems without related ER or hospitalizations, such as chronic liver disease in person who keeps drinking.)

Do NOT check this for applicant who:

• Is physically healthy and knows how to access health care when it's needed.
• Is physically healthy and not likely to need any health care in the next year or two.
• Has health problems but understands them and knows how to access healthcare when it is needed.
• Has diabetes (or other health problems) but can recognize and report problems to MD.
• Has been in ER and hospital, but not due to failure to self-manage health problems.
• Has health conditions resulting from poor self-care (e.g., GI bleed from alcohol and keeps drinking) but understands disease process and has not had ER or hospitalizations for those conditions.
• Needs transportation to appointments, but can make appointments and self-manages health.
• Has missed a few appointments for specific reasons, but is generally able to keep them.
• Has seizures during which loses consciousness, but who otherwise understands their condition and how to manage it.
• Is seen by a nurse out of agency or nurse habit, e.g., doing monthly visits to check on the person. Functional screen should be based on what the person needs, not what the nurse is doing as part of agency routine.
• Receiving medical or skilled nursing services in a primary care setting.

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4.13 Managing Psychiatric Symptoms

Needs assistance (by a person other than a physician) to manage mental health symptoms (e.g., hallucinations, delusions, mania, depression, anxiety, etc.)

The person needs help from others because they are unable to self-manage mental illness symptoms. "Unable to self-manage" means the person:

• Is unable to recognize symptoms when they're starting;
• Is unable to respond when symptoms start;
• Does not understand contributing factors and corrective actions.

This item looks for help needed to recognize and respond to symptoms of mental illness - beyond the typical emotional support we all get from friends and loved ones (or, for some, clergy). If such informal supports are going beyond this to monitor for signs of serious mental illness and help the individual respond to those symptoms, then that more advanced assistance counts for this item.

This item is limited to psychiatric symptoms; substance use problems are addressed separately in the Risk section of the MH/AODA FS. Although MH and AODA problems can be inextricably enmeshed in real life, providers still distinguish MH from AODA treatment.

Check this for applicant who:

• Has schizophrenia and needs parents to monitor symptoms and call the psychiatrist or MH staff with problems, as applicant is unable to do so.
• Has bi-polar disorder and does not yet recognize when symptoms are getting worse.
• Becomes depressed and stops going to work; needs assistance to recognize and cope with depression and to avoid losing job.
• Can not recognize when mania is starting, so has set up intervention plans and contracts with family and friends to monitor for it and help respond.
• Is learning coping skills, but still needs regular mental health support from case manager.
• Has severe bulimia and must be monitored every day for that; her parents do this but if they couldn't, paid supports would be needed.

Do NOT check this for applicant who:

• Can recognize and self-manage symptoms.
• Calls psychiatrist whenever he or she has problems or concerns.
• Independently accesses community resources (such as peer support groups, or a spiritual advisor or therapist) as part of self-care.
• Has chronic "voices" (auditory hallucinations) but can cope with them, and calls psychiatrist when they get worse.
• Processes emotions with friends, but friends don't need to help monitor symptoms.

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4.14 Hygiene and Grooming

Needs assistance to maintain basic hygiene and grooming.

Screeners must consider this item in the context of the applicant's culture, not the screener's own culture or values. In some cultures, some amount of body odor, hair grease, or dirty nails or clothes is acceptable. The MH/AODA FS looks for problems, help needed, for the applicant to succeed in their own culture.

Check this for applicant who:

• Will not bathe without someone (either family or MH practitioners) coaxing them into it every week or so.
• Has strong body odor and is clearly in need of hygiene (by standards of applicant's culture, not the screener's culture).

Do NOT check this for applicant who:

• Has very casual or unusual clothes and hairstyle, but is clean and without body odor.
• Has some odor, grease, or dirt, but within acceptable levels for own culture.
• Has lice. (Lice can appear even in well-groomed people, so having lice does not mean the person needs help from others with hygiene.)

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4.15 Taking Medications

Needs assistance with taking medications.

Competent adults do have the right to refuse medications. See Section 4.12 about when the person chooses not to take medications versus when they needs help from others because they are unable to self-manage current health conditions or health risks. "Unable to self-manage" means the person:

• Is unable to recognize problems related to meds;
• Is unable to respond to problems related to meds (such as calling MD);
• Has a history of failure to self-manage health resulting in multiple ER visits or hospitalizations (inpatient or out-patient).

NEEDS SOMEONE TO ADMINISTER REGULAR IM (intramuscular) INJECTIONS

Check this for applicant who:

• Goes to clinic every three weeks to receive IM Prolixin.
• Has her mother inject her IM meds without problems.

Do NOT check this for applicant who:

• Receives subcutaneous (just under the skin) Vitamin B injections from a nurse.
• Needs someone to administer their insulin (that's subcutaneous, not IM).
• Self-administers subcutaneous injections (e.g., insulin).
• Self-administers IM shots.

ASSISTANCE NEEDED WITH TAKING OTHER (non-IM) PRESCRIBED MEDS

This applies to any medications prescribed (by an MD or other prescriber, e.g., an advance practice nurse or physician's assistant) for psychiatric or other medical conditions. It does not include over-the-counter meds.

"Assistance" includes any of the following:

• Administering medications: Actually giving them the meds.
• Observation of self-administration: Watching them take the meds to ensure they are taking them.
• Verbal reminders to take meds (can include phone reminders).
• "Setting up" medications in med boxes, cassette machines, or syringes.

The MH/AODA FS is intended to capture what individuals' needs, not merely what they are receiving because of providers' habits or philosophy. This distinction is particularly challenging with medication administration. Residential or treatment center staff, for example, may dispense medications mostly because of convenience or liability concerns. A particular individual may or may not be able to take their meds without such help. As much as possible, screeners should try to ascertain whether the individual is in fact independent with taking meds, regardless of what a provider does.

A special exception to this is court orders: Screeners can check this item for medication assistance that MH/AODA providers feel is required to provide for consumers under court orders for MH treatment. The frequency marked on the MH/AODA FS should correlate with the frequency you would include in a service/treatment plan for this person.

Check this for applicant who:

• Would not take psych meds without MH staff or family directly cueing and watching him or her take them.
• Only takes their meds if parents call to remind them every day.
• Has major mental illness and is very old and needs someone to hand them their heart and blood pressure pills several times a day.
• Is under court orders and does not take meds consistently unless case manager visits every week to coax him or her into taking them.
• Refuses to take prescribed meds for other (non-psych) health conditions and cannot understand the dangers of not taking them.
• Refuses to take prescribed meds for other (non-psych) health conditions, does understand the risks, and has had ER or hospitalizations as a result.
• Says doesn't need meds, but agrees to someone cueing him or her to take them.
• Does not want meds but is under court orders to take them and agrees to plan to assure he or she takes them.
• Just stopped taking psych meds and needs intensive interventions (negotiations, coaxing, coaching, etc.) to get back on them.

Do NOT check this for applicant who:

• Takes meds regularly without anyone reminding them.
• Is under court orders to take meds, but has been taking them consistently as prescribed without any reminders or help from others.
• Fills own med box every week.
• Receives pills from day center staff when there three times a week, due to provider policy, but is in fact completely independent with meds.
• Misuses over-the-counter meds, but takes prescribed meds as recommended or has no prescribed meds.
• Refuses to take prescribed meds for other (non-psych) health conditions but understands the med, the condition, and the risks, and has not had ER or hospitalizations as a result.
•  Is taking a "med holiday."

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4.16 Monitoring Medication Effects

Needs assistance monitoring effects and side effects of prescribed medications.

This item applies to any medications prescribed (by an MD or other prescriber, e.g., an advance practice nurse or physician's assistant) for psychiatric or other medical conditions. It does not include over-the-counter meds.

Monitoring medication effects includes all of the following:

1. Recognize effects and noticeable side effects of prescribed medications,
2. Report med effects or new problems to a prescribing professional, and
3. Follow any med or dose changes recommended by the prescriber.

When blood tests must be done, monitoring med effects also includes:

4. Doing self-tests, for example, blood sugar checks; or going to clinic for blood draws.

A person is "independent" in Monitoring Med Effects if they are able to do all 3 (or 4, if applicable) of these steps.

If the person cannot do all 3 or 4 of these steps, they needs assistance from someone else (someone besides the prescriber) to notice problems, report them to the prescriber, and to help the consumer follow through with the prescriber's recommendations. Since prescription meds always involve a prescriber, the prescriber's actions in themselves do not constitute the "assistance" sought for in this item. Thus, visits or contacts with a physician or other prescriber do not count. Instead, this item asks whether the consumer needs a "third party" as intermediary between them and the prescriber.

Check this for applicant who:

• Has schizophrenia and unstable diabetes and needs someone to check their blood sugars and watch for signs of high or low blood sugar and respond accordingly.
• Is unable to notice or report med side effects and needs someone else to do so, as is on prescribed meds with potential side effects.

Do NOT check this for applicant who:

• Is not on any prescribed medications.
• Has diabetes with a history of dangerously low blood sugars, but has learned to recognize when blood sugar level is getting low and has a snack at those times.
• Can check own blood sugar levels, although doesn't always do it.
• Goes to the clinic every three weeks for lab test for medication side effects.
• Can call doctor to report problems, and can follow instructions such as a dosage change.

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4.17 Monitoring Meds and/or Managing Symptoms

With prescribed psychiatric medications, there is a significant overlap between this "Monitoring for Medication Effects" question and the "Managing Psychiatric Symptoms" question elsewhere in the MH/AODA FS. When psychiatric meds are being adjusted to reduce psychiatric symptoms, screeners will check both "Managing Psychiatric Symptoms" and "Monitoring for Medication Effects." Sometimes only one of the items would be checked, for example:

• Needs help with "Monitoring for Medication Effects" but not with "Managing Psychiatric Symptoms"
  • Joey has none of the symptoms (hallucinations, delusions, mania, depression, anxiety, etc.) listed under "Managing Symptoms," but does need someone to monitor for med side effects and report them to MD.
    
    
• Needs help with "Managing Psychiatric Symptoms" but not with "Monitoring for Medication Effects"
  • Shar needs regular support from several people to help her manage her anxiety and depression, but is capable of noticing med effects, reporting them, and making changes as instructed by her psychiatrist.

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4.18 Transportation

The ability to drive a regular or adapted vehicle.

• Person drives.
• Person drives but there are serious safety concerns.
• Person can not drive due to physical, psychiatric, or cognitive impairment. Includes no driver's license due to medical problems (e.g., seizures, poor vision).
• Person does not drive due to other reasons (e.g., lost license, has no car).

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4.19 Physical Assistance

Needs assistance to physically accomplish the following tasks: (Check all that apply)

This item is intended to indicate when help is needed with these tasks due to PHYSICAL LIMITATIONS. These applicants may be eligible for long-term care services in addition to mental health services. (These factors will also impact costs in MH services.)

Independent = No PHYSICAL limitations requiring assistance with any of the tasks listed below. (Limitations due to mental illness or cognitive limitations are indicated in the previous Community Living Skills items.)

• Bathing
  The ability to shower, bathe or take sponge baths for the purpose of maintaining adequate hygiene. This also includes the ability to get in and out of the tub, turn faucets on and off, regulate water temperature, wash and dry fully.
  
  
• Dressing
  The ability to dress and undress as necessary and choose appropriate clothing. Includes the ability to put on prostheses, braces, and/or antiembolism hose (e.g., "TED stockings") with or without assistive devices. Includes fine motor coordination for buttons and zippers. Includes choice of clothing appropriate for the weather. (However, difficulties with a zipper or buttons at the back of a dress or blouse do not constitute a functional deficit.)
  
  
• Toileting
  The ability to use the toilet, commode, bedpan, or urinal. This includes transferring on/off the toilet, cleansing of self, changing of pads, managing an ostomy or catheter, and adjusting clothes. Check this box if the applicant needs physical help from another person, or if they use a commode, elevated toilet seat, ostomy, urinary catheter, or regular bowel program or is incontinent more than monthly.
  
  
• Mobility in Home
  The ability to move between locations in the individual's living environment (defined as kitchen, living room, bathroom, and sleeping area). For purposes of the functional screen, this excludes basements, attics and yards.
  
  
• Transferring
  The physical ability to move between surfaces: from bed/chair to wheelchair, walker or standing position. The ability to get in and out of bed or usual sleeping place. The ability to use assistive devices for transfers. Excludes toileting transfers. Check this box if the person needs physical help from another person, or if they use a mechanical lift, transfer board, or trapeze.

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