GUIDE Consent Form - Bloom Healthcare

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Demographics

These questions are intended to be completed by the patient’s primary caregiver. Please answer for yourself (primary caregiver), not for the patient.

Caregiver First Name(Required)

Caregiver Last Name(Required)

Address(Required)

Caregiver Street Address Caregiver City Caregiver State Caregiver Zip Code

Caregiver Email Address(Required)

Caregiver Phone Number(Required)

Caregiver Phone Type(Required)

Home (landline)

Mobile

Business

Caregiver DOB(Required)

YYYY dash MM dash DD

Caregiver Sex(Required)

Male

Female

Prefer not to disclose

Caregiver Race(Required)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other

Prefer not to disclose

Caregiver Ethnicity(Required)

Hispanic or Latino

Not Hispanic or Latino

Prefer not to disclose

Are you (not the patient) a Medicare beneficiary?

Yes

If Yes What is your Medicare Beneficiary ID?

What is your relationship to the patient?(Required)

Spouse

Domestic Partner

Daughter

Son

Sibling

Other family member

Friend

Other non-family member

How long have you served as the patient’s primary caregiver?

Do you live with the patient?

Yes

What are your top concerns for the person you care for, that you hope their primary care provider will address?(Required)

Do you have any concerns that the patient may be experiencing neglect or abuse?(Required)

Yes

Do you have any concerns that the patient may be experiencing exploitation?(Required)

Yes

Consent

Do you give Bloom Healthcare permission to submit information to CMS in order to check the patient’s eligibility for the GUIDE model?

Yes

Caregiver Burden Survey

One of the goals of the GUIDE program is to reduce burden and strain for those who are caring for someone with dementia. Medicare requires us to ask the following questions to identify areas where caregivers may be struggling so that we can help connect you to resources that can help.

Do you feel that the person with dementia you support asks for more help than he/she needs?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that because of the time you spend with the person you support that you do not have enough time for yourself?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel stressed between caring for the person you support and trying to meet other responsibilities for your family or work?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel embarrassed by the behavior of the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel angry when you are around the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that the person you support currently affects your relationship with other family members or friends in a negative way?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Are you afraid of what the future holds for the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel like the person you support is dependent upon you?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel strained when you are around the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel your health has suffered because of your involvement with the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that you do not have as much privacy as you would like because of the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that your social life has suffered because you are caring for the person with dementia?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel uncomfortable about having friends over because of the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that the person you support seems to expect you to take care of him/her as if you were the only one he/she could depend on?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that you do not have enough money to care for the person you support in addition to the rest of your expenses?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that you will be unable to take care of the person you support much longer?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that you have lost control of your life since their illness?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you wish you could just leave the care of the person you support to someone else?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel uncertain about what to do about the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel that you should be doing more for the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Do you feel you could do a better job in caring for the person you support?(Required)

Never (0)

Rarely (1)

Sometimes (2)

Quite Frequently (3)

Nearly Always (4)

Overall, how burdened do you feel in caring for the person you support?(Required)

Not at all

A little

Moderately

Quite a bit

Extremely

Patient Quality of Life Survey

Another goal of the GUIDE program is improving quality of life for people with dementia. Medicare requires us to ask the following questions to identify areas that may be negatively impacting quality of life so that we can address them. Please answer on behalf of the person with dementia you care for.

In general, would you say the health of the person you support is:(Required)

Poor (1)

Fair (2)

Good (3)

Very Good (4)

Excellent (5)

In general, would you say the quality of life for the person you support is:(Required)

Poor (1)

Fair (2)

Good (3)

Very Good (4)

Excellent (5)

In general, how would you rate the physical health of the person you support?(Required)

Poor (1)

Fair (2)

Good (3)

Very Good (4)

Excellent (5)

In general, how would you rate the mental health of the person you support, including mood and ability to think?(Required)

Poor (1)

Fair (2)

Good (3)

Very Good (4)

Excellent (5)

In general, how do you think the person you support would rate their satisfaction with social activities and relationships?(Required)

Poor (1)

Fair (2)

Good (3)

Very Good (4)

Excellent (5)

In general, how well does the person you support carry out their usual social activities and roles? (This includes activities at home, at work and in the community, and responsibilities as a parent, child, spouse, employee, friend, etc.)(Required)

Poor (1)

Fair (2)

Good (3)

Very Good (4)

Excellent (5)

To what extent is the person you support able to carry out their everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?(Required)

Not at all (1)

A little (2)

Moderately (3)

Mostly (4)

Completely (5)

In the past 7 days, how often has the person you support been bothered by emotional problems such as feeling anxious, depressed or irritable?(Required)

Always (1)

Often (2)

Sometimes (3)

Rarely (4)

Never (5)

Over the past 7 days, how would you rate the fatigue on average of the person you support?(Required)

Very Severe (1)

Severe (2)

Moderate (3)

Mild (4)

None (5)

Over the past 7 days, on a scale of 0-10 (with 10 being the worst pain imaginable and 0 being no pain at all) based on what you know, how would you rate the pain on average of the person you support?(Required)

Please enter a number from 0 to 10.

Supports & Services

Which of the following Home/Community Based Services, Coordination Based Services, and/or Specialist or Behavioral Health Providers does the patient use?(Required)

Care coordination services (i.e. GUIDE program, Alzheimer’s Association Support Group).

Behavioral Health Provider

Specialty Health Provider

Community-based services (i.e. senior centers, meal programs)

Home and community-based services (i.e., in-home care, respite care, transportation)

Other

None

Knowing this information will help us better coordinate with the patient’s other providers and deliver more seamless care.

If yes, provide details. (Care coordination services)

If yes, add name of practice and provider (Behavioral Health Provider)

if yes, add name of practice and provider (Specialty Health Provider)

Provide Details (Other)

Additional Patient Needs (optional)

Bloom Healthcare can help coordinate services and supports when patients have non-medical needs that affect their health and wellbeing. The following questions are intended to identify these types of non-medical needs.

What is the living situation today of the person you care for?

A steady place to live

A place to live today, but worried about losing it in the future

Do not have a steady place to live (temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

Think about the place where the person you care for lives. Do they have problems with any of the following?

Pests such as bugs, ants, or mice

Mold

Lead paint or pipes

Lack of heat

Oven or stove not working

Smoke detectors missing or not working

Water leaks

None of the above

Please answer whether the following statements were Often, Sometimes, or Never true for the person you care for and their household in the last 12 months.

Within the past 12 months, how often were you worried that the person you care for would run out of food before getting money to buy more?

Often true

Sometimes true

Never true

Within the past 12 months, how often did the food bought for the person you care for not last and you didn't have money to get more?

Often true

Sometimes true

Never true

Transportation

Within the past 12 months, has lack of reliable transportation kept the person you care for from medical appointments, meetings or from getting things needed for daily living?

Yes

Utilities

Within the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in the home of the person you care for?

Yes

Already shut off

Safety

Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.

How often does anyone, including family and friends, physically hurt the person you care for?

Never (1)

Rarely (2)

Sometimes (3)

Fairly Often (4)

Frequently (5)

How often does anyone, including family and friends, insult or talk down to the person you care for?

Never (1)

Rarely (2)

Sometimes (3)

Fairly Often (4)

Frequently (5)

How often does anyone, including family and friends, threaten the person you care for with harm?

Never (1)

Rarely (2)

Sometimes (3)

Fairly Often (4)

Frequently (5)

How often does anyone, including family and friends, scream or curse at the person you care for?

Never (1)

Rarely (2)

Sometimes (3)

Fairly Often (4)

Frequently (5)

Demographics

Consent

Caregiver Burden Survey

Patient Quality of Life Survey

Supports & Services

Additional Patient Needs (optional)

Transportation

Utilities

Safety

(303) 993-1330

(303) 647-3647

12600 W Colfax Ave, Suite B-200
Lakewood, CO 80215

(210) 903-0000

(210) 944-4133

8000 IH-10 West, Suite 201
San Antonio, TX 78230