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_Caregiver Assessment
Step
1
of
6
16%
Patient #
*
include H or P
Currently enrolled as:
*
Hospice patient
Care Connection patient
Assessment type:
*
Initial Assessment
Recertification
Significant Change
Caregiver Demographics
Relationship to patient:
*
Spouse
Child
Sibling
Parent
Friend
Other
If Other, please define:
*
Gender
*
Female
Male
Age
*
18-30
31-50
51-70
71+
Race/Ethnicity
*
African American
American Inidan or Alaska Native
Asian
Caucasian
Hispanic or Latino
Other
Education/Information requested:
Insurance (Medicare, Medicaid, private, etc.)
*
Yes
No
N/A
Respite (in home/short term)
*
Yes
No
N/A
Respite (out of home/longer term)
*
Yes
No
N/A
In-home volunteer support
*
Yes
No
N/A
If yes, please specify need:
*
Facility placement (ALF, SNF)
*
Yes
No
N/A
Social Security/Disability
*
Yes
No
N/A
Veterans Administration benefits
*
Yes
No
N/A
Supplemental insurance (LTC, life, etc.)
*
Yes
No
N/A
Housing concerns
*
Yes
No
N/A
Food assistance (MOW, food stamps, etc.)
*
Yes
No
N/A
Medical transportation
*
Yes
No
N/A
Finances (utilities, medications, etc.)
*
Yes
No
N/A
Medical alert device
*
Yes
No
N/A
Private hire caregivers
*
Yes
No
N/A
Occasional caregiving assistance
*
Yes
No
N/A
Mental health resources
*
Yes
No
N/A
If yes, please explain:
*
Durable medical equipment
*
Yes
No
N/A
Final arrangements
*
Yes
No
N/A
Patient grooming (nails, hair, etc.)
*
Yes
No
N/A
Caregiving "tools" (checklist, med tracker, etc.)
*
Yes
No
N/A
After death checklist
*
Yes
No
N/A
List and explain any additional needs
What level of support do you feel you have from others?
Family support
*
Excellent
Good
Fair
Poor
N/A
Friends/Neighbors
*
Excellent
Good
Fair
Poor
N/A
Employer/Colleagues
*
Excellent
Good
Fair
Poor
N/A
Clergy/Place of Worship
*
Excellent
Good
Fair
Poor
N/A
Did the respondent answer Fair or Poor on two or more?
*
No
Yes, continue to Zarit Burden Interview.
Yes, but caregiver declined Zarit Burden Interview.
Yes, but anticipated short stay.
Based on your answers, we have some additional questions.
Zarit Burden Interview
1. Do you feel that your relative asks for more help than he/she needs?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
2. Do you feel that because of the time you spend with your relative that you don’t have enough time for yourself?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
3. Do you feel stressed between caring for your relative and trying to meet other responsibilities for your family or work?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
4. Do you feel embarrassed over your relative’s behavior?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
5. Do you feel angry when you are around your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
6. Do you feel that your relative currently affects our relationships with other family members or friends in a negative way?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
7. Are you afraid what the future holds for your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
8. Do you feel your relative is dependent on you?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
9. Do you feel strained when you are around your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
10. Do you feel your health has suffered because of your involvement with your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
11. Do you feel that you don’t have as much privacy as you would like because of your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
12. Do you feel that your social life has suffered because you are caring for your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
13. Do you feel uncomfortable about having friends over because of your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
14. Do you feel that your relative seems to expect you to take care of him/her as if you were the only one he/she could depend on?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
15. Do you feel that you don’t have enough money to take care of your relative in addition to the rest of your expenses?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
16. Do you feel that you will be unable to take care of your relative much longer?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
17. Do you feel you have lost control of your life since your relative’s illness?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
18. Do you wish you could leave the care of your relative to someone else?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
19. Do you feel uncertain about what to do about your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
20. Do you feel you should be doing more for your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
21. Do you feel you could do a better job in caring for your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
22. Overall, how burdened do you feel in caring for your relative?
*
Never
Rarely
Sometimes
Quite Frequently
Nearly Always
Total
$0.00
If available, would you participate in:
An ongoing support group for caregivers?
*
A support group that meets regularly, led by hospice team members.
Yes
No
A one-time caregiver "orientation" session?
*
Similar to Grief 101, educational and supportive session to help understand caregiver resources.
Yes
No
A private Facebook group for caregivers?
*
Group set up through the Hospice of the Piedmont Facebook page to share resources, support and connect with other caregivers, monitored by hospice staff.
Yes
No
A volunteer phone support program for caregivers?
*
Volunteer support by phone, 1-3 calls per week.
Yes
No
Additional online caregiver support resources?
*
A patient/caregiver portal with informative posts and videos to support care instructions given by the hospice care team.
Yes
No
