GOVERNOR'S OFFICE OF ELDERLY AFFAIRS

Client's Initials
GOVERNOR'S OFFICE OF ELDERLY AFFAIRS
Louisiana Independent Living Assessment (LILA) Statewide Comprehensive Needs Assessment Form
Assessment Date

MonthDayYear
Date
Re Assessment Date

MonthDayYear
Date
Veteran:

YesN
Veteran Dependent:

YesNo
First Name
Middle Name
Does the Client wish to be evacuated in case of a disaster?

YesNo
Last Name
Client Suffix
Client Maiden Name
Client AKA Name
Marital Status:

DivorcedLegally SeparatedMarriedSingleWidowed
Gender:

MaleFemale
Date of Birth

MonthDayYear
Date
Age
COA Membership Card Declined Accepted
Accepted
Declined
Client's ID: Last 4 of Client's SS #:
Last 4 of Client's SS #
Client's ID
Phone Number
Cell Number:
Client's Mailing Address (if same write SAME):
Street
P.O. Box
Town
Town
State
Zip Code
State
Zip Code_
Other (Individual ($12,060 FY/2017)
Monthly Poverty Guideline per Person: Monthly 1-$1,005 or less 4-$2,050 or less Income: 2-$1,353 or less5-$2,398 or less 3-$1,702 or less 6-$2,747 or less
Household Size:
Medicaid Policy #
Monthly Household Income:
Monthly Individual Income:
Medicare #
Insurance Medicaid:

YesNo
Medical Assistance ID #
Client's Initials
Ethnicity:

Hispanic / LatinoNon Hispanic / LatinoUnknown
In Poverty:

YesNoType option 3
Lives Alone:

YesNoI don't Know
Is Rural:

YesNoDon't Know
High Nutrition Risk:

YesNoDon't Know
NSIP Meal Eligible:

YesNo
From Page 4. Nutrition Score:
ADL Score:
LADL Score:
Eligibility Type: Age 60 or over

Disabled in Elderly Housing

Disabled living with Elderly Person

Food Handlers

Guest/ Staff under 60

I & R Clients

Not indicated

Other

Spouse

Tribal Age Specification

Volunteer
State Resident

YesNo
Duplicate Mail:

Type option 1Type option 2
Abuse/ Neglected/ Exploited:

YesNo
Female Head of Huse-hold:

YesNo
Tribal

YesNo
Understand English:

YesNo
U.S. Citizen:

YesNo
Medicare Eligible:

YesNo
Cognitive Impairment:

Early Onset DementiaMildModerateNoneSevereUnknown
Employment Status:

Declined to stateFull TimeNonePart TimeRetiredUnemployedUnknown
Receiving Social Security:

YesNo
Disabled:

YesNo
Frail:

YesNo
Homebound

YesNo
Language:

EnglishSpanishFrenchItalianRussianGermanOther
Race

American Indian / Alaska NativeAsianBlack / African AmericanNative Hawaiian / Other Pacific IslanderWhite (non-minority / Non- Hispanic)White HispanicOther
Name Emergency Contact

First NameLast Name
Address emergency Contact
Phone Number Emergency Contact
Please enter a valid phone number.
Directions to Client's Home:
Relative / Friend

First NameLast Name
Address of Relative / Friend
Phone Number Friend / Relative
Please enter a valid phone number.
Cell Number Friend / relative
Please enter a valid phone number.
Relationship
Do you have prescription drug insurance?

YesNoDon't know
The client formally authorized release of information. Copy of signed and dated authorization is attached to this assessment

YesNoDon't know
List all the services the client will receive:
Client has been advised that he/she has an opportunity to make volu ntary and anonymous donations for any service they may receive and has received a copy of policy.

YesNoDon't Know
Where did Assesment take place
Client signature

Clear
Date

MonthDayYear
Date
Signature - Assessor

Clear
Date

MonthDayYear
Date
Where did reassessment take place
SIGNATURE Client

Clear
Date

MonthDayYear
Date
Signature- Assessor

Clear
Date

MonthDayYear
Date

Nutrition Health Risk (Tally up answers)

Yes No

• Has the client made any changes in lifelong eating habits because of health problems?	2	0
• Does the client eat fewer than two meals per day?	3	0
• Does the client eat fewer than five servings (1/2 cup each) of fruits and vegetables?	1	0
• Does the client eat fewer than two servings of dairy products (such as milk, yogurt, or cheese) every day?	1	0
• Does the client sometimes have enough money to sometimes buy food?	4	0
• Does the client have biting, chewing, or swallowing problems that make it difficult to eat?	2	0
• Does the client eat alone most of the time?	1	0
Has the client lost or gained ten pounds in the past six months without wanting to?	2	0
• Is the client able to shop, cook, and /or feed themselves (or get someone to do it for them)?	0	2
• Does the client have three (3) or more drinks of beer, liquor, or wine almost everyday?	2	0
• Does the client take three (3) or more prescriptions of over-the-counter drugs daily?	1	0

Combined total (Add YES + NO for your total nutrition score)

If. Score is:

0-2 GOOD! Recheck the Nutritional Score in 6 months.

3-5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyles. Your area agency on aging, senior nutrition program, senior citizens center or health department can help. Recheck your Nutritional Score in 3 mo.

6 or more You are at high nutritional rick. Bring a copy of this checklist the next time you see your doctor, dietitian, or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.

(Be sure to put all three score totals on second page of assessment)

__________________________________________________________________

Can You	Yes	NO		Yes	No	Yes	No	Comment
a) Get around inside your home			ADL
b) Bathe			ADL
c) Dress			ADL
d) Get in and out of bed/chair			ADL
e) Use toilet			ADL
f) Eat			ADL
g) Groom yourself			ADL
h) Manage your money			IADL
i) Do laundry			IADL
j) Take care of shopping			IADL
k)Take your medication			IADL
l) Prepare your meals			IADL
m)Perform heavy home chores			IADL
n)Perform ordinary housework			IADL
o)Take out garbage			IADL
p) Use transportation			IADL
q) Use telephone			IADL

Total ADL Type a label IADL Type a label record the total number of "NO without help" for ADL and IASDL score.
Where was the client interviewed?

HomeHospitalNursing FacilityOther
Name of the person that helps the client?
Name of the agency where assessor works?
Describe where the client was interviewed
What is the helper's relationship to the client?
Did someone help the client or answer question for the client?

YesNo
What is the name of the person conducting this assessment?
Was communication/ language assistance needed for this assessment?

YesNo
What type of communication / language assistance was needed for this assessment?
Does the client have a power of attorney?

YesNo
Does the client have a legal guardian?

YesNo
What is the name of the client's power of attorney?
What is the name of the client's guardian?
Phone number of client's power of attorney
Please enter a valid phone number.
Dose client having living will?

YesNo
If the client does not have a living will, was information provided about advanced directives?

YesNo
What is the client's main problem or reason for referral (when not a standard choice)
Type a question
Who was the client referred by?

SelfFamilyHospitalAgencyOtherUnavailable
Indicate the type if residence that the client currently resides:

House/ Mobile HomePrivate ApartmentPrivate apartment in senior housingResident Home CareNursing HomeUnavailableOther
Select the client's Living arrangement

Lives AloneWith Spouse/partnerLives with spouse and childWith child/childrenInformation UnavailableWith Others
What is the name of the Client's spouse/partner?
Dose the client have any children?

YesNo
Does the client have contact with family often enough?

YesNo
Does the client have contact with friends often enough?

YesNo
Is there a friend or relative that could take care of the client for a few days?

YesNo
How does the client rate his/her health?

ExcellentGoodFairPoorInformation unavailable
Is the client limited in what s/he can do because of the stroke/ neurological condition?

YesNo
How often does bad health, sickness, pain, or disability stop the client from doing things s/he would like to do?

NeverSometimesOftenAlways
In a typical week, during the last 30 days, how often did the client go outside of their residence (no matter for how short period of time)?

Two or more days a weekOne day a week or less
What is the name of the agency that referred the client?
Who referred the client?
Client's Initials
Indicate which of the following conditions/diagnoses the client currently has.

Heart problemsArthritisDiabetesCancerSTROKE/NEUROLOGIcAL PROBLEMSmental/emotional conditionbreathing disordersCataractsUrinary problemsAnkle/leg swellingCognitive impairment/dementiaOther
When the client makes a decision about something how does s/he do it?

Independently and aloneIndependently after talking to family/friendsFollow advice of family/friendsDependentInformation unavailable
What was the client's response when asked. "what year is it?"

Correct answerIncorrect answer
What was the client's response when asked, "what month is it?"

Correct answerIncorrect answer
What was the client's response when asked. "Where are you now?"

Correct answerIncorrect answer
Has the client fallen in the past three months?

YesNo
Does the client use a walker to get around?

YesNo
Does the client use a wheelchair to get around?

YesNo
Does the client have problems with hearing that are not corrected with aids/device?

YesNo
Describe the aids/devices used by the client to correct hearing problems.
Are the client's hearing aids/devices in working order?

YesNoDon't Know
Does the client have problems with vision that are not corrected with aids/devices?

YesNo
Describe the aids/devices used by the client to correct vision problems.
Are the client's vision aids/devices in working order?

YesNoDon't know
Does client have problems with speech that are correct with aids/devices?

YesNo
Describe the aids/devices used by the client to correct speech problems.
Are the client's speech aids/devices in working order?

YesNoDon't know
Does the client often feel sad or blue?

YesNoDon't know
Client's Initials
How many precription medications does the client take?
Is the Client participating in any of the following services or programs?

Attendant services program (not applicable to Louisiana)Medical WaiverHomemaker ProgramHome Health AideNursingSpeech TherapyOccupational TherapyPhysical TherapyHome Delivered MealsEmergency LifelineSenior CompanionWeatherizationCongregate MealsVCIL peer Counseling (Not Applicable to Louisiana)Adult Day ServicesJob Counseling/Vocational RehabilitationFood StampsFuel AssistanceTelephone LifelineMedicaidSSI (supplemental Security Income)V-Script (Not Applicable to Louisiana)QMB/SLMB (Medicare Savings Program: Qualified Medicare Beneficiary/Specified Low Income Medicare Beneficiary)Essential Person ProgramANFCVHAPOther
Does the client want to apply for any of the following services or programs?

Attendant services program (not applicable to Louisiana)Medical WaiverHomemaker ProgramHome Health AideNursingSpeech TherapyOccupational TherapyPhysical TherapyHome Delivered MealsEmergency LifelineSenior CompanionWeatherizationCongregate MealsVCIL peer Counseling (Not Applicable to Louisiana)Adult Day ServicesJob Counseling/Vocational RehabilitationFood StampsFuel AssistanceTelephone LifelineMedicaidSSI (supplemental Security Income)V-Script (Not Applicable to Louisiana)QMB/SLMB (Medicare Savings Program: Qualified Medicare Beneficiary/Specified Low Income Medicare Beneficiary)Essential Person ProgramANFCVHAPOther
Client's Initials
Client NAME:
Client ID#
Date
Nutritional Store (page 4):
Services Requested:
Is this person low income? Yes= 1 No= 0
Is this person a minority? Yes= 1. No= 0
Is this person living alone? Yes= 1. No= 0
What is the person's ADL count from page 4 (score 0-6)?
What is the person's IADL count from page 4 (score 0-6)?
Is the person residing n a rual area? Yes=1. No=0
What age is the person? Below 75=0. 75-84=1 85+=2
What level of support is currently available to this person?High=0 Moderate=1 Very little or none=2
Is the person on a special diet? Yes=1. No=0
Is the person homebound? Yes=1 No=0
Total (tally the previous 10 answers)
Medication Name answer here Primary diagnosis type here directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label
Medication Name answer here Primary diagnosis type here directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label
Medication Name answer here Primary diagnosis type here directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label
Medication Name Type a label Primary diagnosis Type a label directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label
Medication Name Type a label Primary diagnosis Type a label directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label
Medication Name Type a label Primary Type a label diagnosis directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label
Do you have problems or difficulty remembering to take your medications? (select yes or no.). (If necessary, prompt the client by asking is s/he is concerned and forgetting. What steps does s/he take to remember?). [fill out in blank below]

YesNoOther
Please list your drug allergies:
Referral Made:
Client's Initials
Date

MonthDayYear
Date
I Name Address Type a label .
I acknowledge that I have received a Grievance Form for the:

MealsChoreTransportationTelephoneRespiteOutreach
Signature

Clear
Client's Initials
Name

First NameLast Name
Authorize the release of information contained in the Louisiana Assessment (LILA) form to other agencies or entities to deternie eligbility for services.
Signature

Clear
Date

MonthDayYear
Date
Witness

Clear
Client Name
ID #
DOB

MonthDayYear
Date
Age
COMMUNICATIONS WITH CAAREGIVERS AND RELATIVES We may use or disclose your information to notify or assist in notifying: (1) a family member, personal represenaative, or caregiver reguarding your location and general condituon; (2) a family member, other relative, close personaal friend, or any other person you authorize, as necessary for and directly relevant to that person's involvmnet in your care. Please sign and authorized person below:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Signature

Clear
Date

MonthDayYear
Date
Rapides Council on Aging

204 Chester Street

Alexandria, LA 71301

(318) 445-7985
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