What should be included in a new client assessment?
I’ve spent the last few weeks exploring client intake and assessment processes with a handful of well-known, highly-successful agencies. Interestingly, their processes and how/when they collect the information vary quite a bit.
Based on the experience, I’ve compiled a comprehensive new client assessment workflow that could work well for anyone building this process in their own agency or looking for ways to streamline their existing process.
One caveat to remember is that your state may have other specific requirements.
A quick overview of typical client assessment documents and when you complete them:
- New Client Inquiry - phone call / website inquiry
- Client Intake Form/Pre-Care Assessment - can be sent electronically and filled out by the client/family OR completed over the phone by a member of your team. Should be stored in client profile in your scheduling software
- Client Assessment - completed in the home with one of your nurses. Optional Add-ons: Profile/Personality Test, Home Safety Inspection, Payer Details, Letter of Intent, etc.
- Care Plan - compiled information from the intake and assessment forms. Should shared with client/family, stored in client profile in your scheduling software, used as a source of truth for the caregiver providing the care, and updated regularly by state law or as the care needs change
- Client/Family signs Service Agreement
- Client Starts Care
What to gather in your Intake/Pre-Assessment Process:
- Name of Contact
- Phone
- Name of Person Receiving Care
- Address
- Care Goals
- Schedule (days of the week & times)
- Gender
- Ethnicity
- Date of Birth
- Height
- Weight
- Marital Status
- Spouse Name
- Lives With / Relation
- Religion / Attends Services
- Doctors
- Advanced Care Directive Y/N
- Veteran Y/N
- Long Term Care Insurance Y/N
- Past Profession
- Hearing
- Vision
- Speech
- Other
- Areas of Care Assistance (Should include checkboxes for ADLs and IADLs as well as room for addional notes)
- Allergies
- Continence Needs
- Receiving Current Services (checkbox) Home Health, Hospice, Home Care, None
- Medical Conditions (checkbox)
- Mental Behaviors
- History of…
- Medications & Supplements (Should address questions like such as whether they need reminders, how many times, per day, number of medications and supplements, who manages them, and if there is a separate schedule sheet for them)
- Meal Assistance
- Dietary Needs (Should include days/times for meals, favorite foods, and preferred snacks)
- Activities (split up by at home and away from home, including their favorite places to visit or shop)
- Friends/Family/Neighbors
What to gather in your In-Home Assessment Process: (think of this as a verification of the self-reported information on the intake form)
- Ambulation
- Transferring
- Bathing
- Continence
- Dress/Grooming
- Eating/Feeding
- Toileting
- House work
- Laundry
- Medication
- Money/Bills
- Pet Care
- Preparing Meals
- Shopping
- Using Telephone
- Companionship
- Transportation
*Bonus: What to gather in your In-Home Safety Inspection:
- Name of Inspector
- Name of Client
- Type of Housing
- Areas of focus within the house/dwelling/property
- Cleanliness/Sanitary
- Smoke Detectors
- Electrical panel accessible
- Temperature
- Wheel-chair accessible
- Security system
- Medical alert device
- Other Safety Recommendations/Notes