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Georgia Department of Human Resources Division of Aging Services

Requirements for Non-Medicaid Home and Community Based Services

Section 100

Administrative Guidelines and Requirements
for Area Agencies on Aging

§114 Guidelines and Requirements for Client Assessment

§114.1

Purpose

§114.2 Scope and Purpose

1

December 2003
Revised 11/2009

This chapter establishes the guidelines for quality
service and accountability for Area Agencies on Aging,
(AAAs) Area Agency contractors, and subcontracting
service providers when conducting client assessments
for non-Medicaid Home and Community Based Services
(HCBS). 1 These are the minimum requirements to be
followed if AAAs are not contracting for comprehensive
HCBS case management services, of which client
assessment is one component. These requirements also
establish the Determination of Need-Revised as the core
assessment instrument for all non-Medicaid Home and
Community Based Services. In addition, this reiterates
the requirement that AAAs/providers assess the
nutrition risk level of all applicants for and recipients of
Nutrition Program Services, using the Nutrition
Screening Initiative DETERMINE Checklist and Level I
Screening, when indicated. The Division will periodically
review the need to establish additional assessment
domains, instruments and data sets in the future. Refer
to Appendix 114-A for an overview of the DON-R and
NSI instruments.
Client assessment, a component of comprehensive Case
Management, encompasses those activities which
directly relate to the initial face-to-face comprehensive
assessment and periodic reassessment of applicants
and program participants by the Area Agency on Aging
and/or its subcontractor(s). The purpose of these
guidelines is to
(a)

eliminate the duplication of assessment activities;

(b)

assure timely completion of assessments and
reassessments;

(c)

assure that assessments are conducted
accurately and consistently within each PSA, and
statewide, and reflect change over time in clients’
conditions and circumstances;

(d)

assure that the services planned, ordered and
provided are appropriate for a client’s situation
and condition on a continuous basis; and

These guidelines do not apply to services provided through the Long Term Care Ombudsman Program, the
Elderly Legal Assistance Program, Elder Abuse Prevention Program , Service Assistance to Victims of Abuse (SAVA),
GeorgiaCares or the Senior Medicare Fraud Patrol.

(e)

§114.3 Objectives

§114.4 Staffing

One of the primary objectives of initial assessment is to
confirm and expand upon the initial information obtained
at telephone screening, through a more thorough
evaluation of eligibility, functional impairment level,
unmet need for care, level of nutrition risk, and other
various individual needs of an applicant for services,
using assessment instruments specified by the Division.
The ultimate goal is the development of an
individualized plan of care or service plan, in
collaboration with the client, and caregivers, when
present, through which care needs will be met by one or
more service providers or other community resources.
The primary objective of periodic reassessment is to
review all criteria related to initial and subsequent
assessment findings, so that any necessary adjustments
in service planning and delivery may be made, based on
the client's most current status and situation.
(a)

Area agencies shall assure that staff performing
assessment activities, at either the AAA or
subcontract agency level, shall be competent,
ethical, sufficient in number and qualified by
training and/or experience to conduct face-toface client and caregiver assessment interviews,
using the instruments, tools, and data
collection/management systems specified by the
Division.

(b)

Staff conducting assessment activities shall have
specialized knowledge of older persons, with
particular strength in the area of assessing the
variables that affect health and functioning.

(c)

§114.5 Assessment Activities

provide the basis for evaluating the effectiveness
of service planning and measuring service
quality.

Area agencies are responsible for identifying
training needs of both AAA and provider staff and
notifying appropriate Division staff if they need
technical assistance or assistance with providing
training.

At a minimum, staff responsible for client assessment
will perform the following activities:
(a)

appraisal of the need for service interventions
through gathering and critical, objective
evaluation of relevant data. This includes
assessment and documentation of the
applicant/client's degree of functional
impairment; unmet need for care; dietary
needs; and eligibility and appropriateness for
non-Medicaid Home and Community Based
Services. Other domains include, but are not
limited to mental/cognitive status; social/

spiritual/ emotional status; health/medical
status and history; financial resources; status of
primary caregiver; home environment; risk
factors for abuse, neglect or exploitation; and
need for assistance with advance directives or
other legal issues.
(b)

assessment of past and present resource
utilization; health conditions/impairment levels,
past and present treatment or service plans;
desired short term and long term outcomes and
goals; service plans, and provider options;

(c)

periodic reassessment of the client, within the
standards established for each program or
service, including updating information in client
records, maintained in either paper or electronic
form, as appropriate and necessary, to
determine any changes in the client's status,
situation or circumstances which impact his/her
functional level and need for assistance;

(d)

travel to and from the homes of
applicants/clients for the purpose of assessment
or reassessment;

(e)

assessment, reassessment and documentation,
where appropriate, of caregiver status, using
criteria or instruments specified or approved by
the Division;

(f)

telephone follow-up with clients and caregivers,
when appropriate and necessary, in accordance
with program and service requirements;

(g)

data collection, data entry, and programmatic
reporting.

§114.6 Service Neutrality and
Organizational Placement
Ideally assessment, as a component of Case
Management, is service neutral; that is, performed
independently by appropriately trained personnel who
are not employed by an organization that also contracts
with the AAA to provide supportive and other services.
AAAs may elect one of the following options for provision
of client assessment:
(a)

the AAA provides comprehensive Case
Management, including initial assessment, for
those persons deemed appropriate to receive
non-Medicaid HCBS and who would benefit from
case management assistance, either on a short
term or long term basis; or

(b)

the AAA conducts the initial assessment only
(and 30-day follow-up contacts, if desired) of
those applicants for service who are determined
appropriate for non-Medicaid HCBS, and
subcontracts for the provision of comprehensive
case management including care planning,

service provision, periodic reassessments, record
maintenance, and reporting; or
(c)

the AAA subcontracts for the provision of
comprehensive case management services,
including initial assessment, with a Case
Management Organization (CMO); or

(d)

the AAA includes in its contractual expectations
that subcontractors conduct comprehensive
assessments for persons referred to them for
services. If the AAA elects this option, it will
establish procedures which assure that
assessments are objective, comprehensive in
addressing all components described in §114.5
(a) and (b) and yield care plans which focus on
the remaining abilities of the client as well as the
impairments, are goal–based, and not biased
toward the services offered by the assessing
entity. AAAs shall develop protocols by which
clients served by more than one organization do
not receive duplicate assessments, and that
services provided by several providers are
coordinated through a single plan of care. (Also
see §114.9, regarding coordination with the CCSP
and Appendix 114-B for the process flow for
coordination of assessments.)

(e)

Providers that conduct comprehensive
assessments shall assure that they will not
accept clients for whom their services are
inappropriate, based on the completed
comprehensive assessment. The AAA will work
with providers to establish protocols for having
inappropriate referrals re-screened and referred
to appropriate resources.

(a)

Initial Assessments. Following AAA telephone
screening, and subject to the availability of
services, AAAs may refer clients to appropriate
providers and authorize them to begin services
prior to the completion of a comprehensive initial
face-to-face assessment. Either a CMO or the
provider will complete the full initial assessment
within ten business days of service initiation.
AAAs which exercise this option must assure that
providers adjust services to appropriate levels
based on the full assessment and reflected by
care plans developed by case management
staff/provider staff. Also see §114.5(e) above
regarding arrangements/ referrals for clients
who are found to be inappropriate for any
reason 2 for the original service requested.

amended 12/ 2003

§114.7 Initial Assessment
and Reassessment Intervals.

2

Applicants may be found to be inappropriate when the need for the requested service cannot be confirmed
by the full assessment or when the person’s needs exceed the service organization’s capacity to assure his/her safety
in the home or community.

(b)

Follow-up. AAA/CMO/provider staff conducting
initial assessment will provide telephone follow
up with clients/caregivers at the end of the first
thirty (30) days of service delivery to determine
client/caregiver satisfaction with services. If
initial assessment is conducted independently of
ongoing case management, staff performing
initial assessment activities are responsible for
providing and documenting 30-day follow-up and
for conveying any client/caregiver concerns or
necessary changes in service levels/delivery to
appropriate staff of the CMO or provider agency.
Also as a part of the 30-day follow-up,
responsible staff will review DON-R scores for
both functional impairment and unmet need for
care and if any changes in either domain have
occurred as a result of the introduction of
services/supports, staff will re-score the DON-R
to reflect actual impairment level and unmet
need for care and enter an updated DON-R into
AIMS. See Appendix 114-A for examples of
DON-R scoring, reflecting the implementation of
the care plan and the introduction of services and
supports.

(c)

Reassessments. Designated staff will conduct
the first complete reassessment for non-Medicaid
services in accordance with standards established
for each service, to confirm the client’s continued
eligibility and appropriateness for service, or
whenever there is any change in client condition,
status or circumstances that would affect the
need for a change in service levels and/or
additional services to be provided. Also see (b)
preceding for protocol for re-scoring the DON-R
to reflect the introduction of services/supports.

(a)

The entity conducting client assessment activities
shall establish for each participant a confidential
record in a form designated or authorized by the
Division, which is protected from damage, theft,
and unauthorized inspection, and which is made
available for monitoring and audit purposes. The
record shall contain, at a minimum, the following
information in form and format provided by or
approved by the Division:

Revised 6/2009

Revised 11/2009

§114.8 Client Records and
Records Management

(1)

Intake and screening information;

(2)

documentation of eligibility, assessment
and reassessment;

(3)

service/care plans;

(4)

notes regarding significant client contacts,
activities, including care plans; and

(4)

procedures for emergency care.

§114.9 Joint Service Provision
by Non-Medicaid Providers
and the Community Care
Service Program.

(b)

Staff responsible for conducting initial client
assessments for HCBS shall collect required data
and initiate AIMS data entry either directly or by
providing all required data to data entry staff.

(c)

AAAs shall negotiate with contract providers to
designate a “lead agency” to coordinate care and
services when there are multiple HCBS providers
involved with a client. AAAs are to assure that
only one assessment per client per assessment
interval is recorded in AIMS, except as noted
here: Information about both care givers and
care receivers may be indicated and recorded for
the Title III-E National Family Caregiver Support
Program, depending on the mix of services
provided.

(d)

The AAA shall develop and implement written
procedures to be followed by staff performing
assessment activities at any level to obtain the
written consent of the client for the release of
confidential information to other providers when
referrals are made.

(a)

Primary Assessment: When a client receives
both non-Medicaid and Community Care Service
Program services, the CCSP assessment and
resulting care plans are primary and should
incorporate and reflect the non-Medicaid services.
Non-Medicaid HCBS providers have no further
responsibility under these policies for
assessment/service planning in those cases, but
will communicate and work with the Care
Coordination Agency regarding need for
adjustments in service levels and care plans
based on their observations over the course of
providing services. (Please note that NonMedicaid HCBS providers that are licensed by the
State Office of Regulatory Services as private
home care providers may have additional
requirements for assessment pursuant to those
regulations.)

(b)

Electronic client records and reporting: To
comply with federal and state reporting
requirements, AAAs or other designated entities
will continue to enter any additional client data
required for non-Medicaid services into AIMS to
document and report each non-Medicaid service
provided.
AAAs shall establish protocols and procedures for
obtaining from the CMO/provider necessary data
from the assessment/care plan information.

(c)

Nutrition risk assessment: If a client receives
services through the CCSP and home delivered
meals from a non-Medicaid provider, the
AAA/CMO/nutrition service provider will obtain
nutrition risk scores from the CCSP Care
Coordinator and enter the data in the AIMS client
record.

(d)

Older Americans Act Title III-E National Family
Caregiver Support Program Assessments:
A
CCSP client may have a caregiver who is
identified as the client for the NFCSP and who will
be assessed using instruments identified by the
Division. A separate record for the caregiver as
client is established in the AIMS. DON-R or other
CCSP client data may be shared, if this
information is essential to develop a plan of
intervention for the care receiver and is needed
to provide relevant information to support service
providers.

§114.10 Conditions for Referrals
to Other Services.
When staff discover conditions during the assessment
process which warrant referral, they shall assist clients
in taking advantage of other services, whether provided
through the aging network or through another
community, health, medical, pastoral or legal resources.
Staff shall document such referrals in the client record,
and the assistance or services obtained in the care plan,
if of an ongoing nature.
§114.11 Recordkeeping and
Reporting.

AAAs/subcontractors shall maintain in the manner
prescribed by the Division any such records, in addition
to client records, as may be necessary for overall
program management and report in compliance with the
Division's policies and procedures.

§114.12 AAA Monitoring.

The Area Agency shall conduct periodic (at least annual)
reviews of documentation in client records of
assessment and reassessment activities, (including
establishing procedures for self-review, if the AAA is
providing assessment directly) to verify accuracy,
completeness and timeliness of data collection and
entry, and that activities are performed in compliance
with these policies and procedures. The Division may
monitor client assessment records at the AAA and
subcontract provider levels, to assure compliance with
all applicable requirements.

§114.13 Quality assurance.

The AAA shall periodically, but not less than once
annually, evaluate the effectiveness of client assessment
activities (if provided as a stand alone activity, not as a
part of comprehensive case management), to determine
the degree of accuracy of assessment and reassessment
activities and the degree of correlation of care plans to
assessment data (including self-review procedures, if
applicable). The AAA shall determine the degree to
which the assessment component of case management

contributes to the development of care plans which
support maintenance or improvement of client status.
The AAA will arrange for or provide training and
technical assistance, when indicated, to improve
assessment results.
§114.14 Integration of Client
Assessment Activities

The Area Agency shall assure that initial and ongoing
client assessment activities are conducted in such a way
as to provide maximum coordination and integration
with its intake, screening, and information and
assistance processes and with ongoing case
management, at whatever level that activity occurs.
The area agency may, through the negotiation of
subcontracts, delegate any and all components of case
management (except for telephone screening) including
client assessment. The area agency will document that
the integration of the services has occurred or will occur
as a result of the agency's leadership. The Division may
request documentation at the time of submission of a
proposed area plan, area plan amendment or
update; at the time of a program review or quality
assurance review; or at any other time the information
is needed as a part of program evaluation.

§114.15 Implementation Date This chapter incorporates and amends policies originally
transmitted as DAS Procedural Issuance 146, “Client
Assessment for Non-Medicaid Home and Community
Based Services,” April 21, 2001, which took effect July
1, 2001 for SFY 2002. These policies and procedures
supersede Procedural Issuance 146 in its entirety and
take effect upon issuance. Area Agencies shall have
adequate time to develop protocols and implement any
changes in the client assessment process as may be
necessary.

Appendix 114-A
Core Assessment Instruments for
Non-Medicaid Home and Community Based Services

114-A-1.1

About the DON-R

The Determination of Need-Revised (DON-R)
assessment instrument was developed during 1987
through 1989 by a team of researchers at the
Gerontology Center of the University of Illinois at
Chicago for use by the Illinois Department on Aging’s
statewide network in determining eligibility for home
and community based services, including its Medicaid
waiver program. The DON not only provides the basis
for determining program eligibility, but also provides
sufficient information for case managers to evaluate
care needs and develop plans of care.
The DON is used as a basic individual needs assessment
to determine where there are deficits in functioning and
where there are remaining strengths, including the
presence or absence of a support system. The DON
provides documentation of the need for assistance
across a range of impairments and is a true ordinal
scale. An ordinal scale provides clearly defined
meanings for each level of impairment, each level of
unmet need for care and each functional activity. Thus
changes in score represent actual changes in capacity
and/or need for assistance and the scoring can be used
to track changes over time.
When originally field tested, the DON was normed to a
nursing home population on the impairment scale.
People in the community with impairment level scores of
15 or higher are similar in their degree of impairment to
the upper two-thirds of a nursing home population.
However, it is the unmet need for care which has more
bearing on the actual potential for placement outside the
home. The availability of a continuous range of scores
means that staff responsible for planning or assisting
others with planning for care are able to develop plans
to order only the actual amount of service needed and
can provide the basis for controlling costs. The DON can
assist in developing a plan of care which promotes
independence in the community, or if assessing the
strengths of someone already in a nursing home, to help
the resident remain as independent as possible in that
setting.

114-A-1.2 Summary of the Determination of Need-Revised (DON-R) Assessment
of Functional Impairment and Unmet Need for Care
Column A
Function

Column B

Level of Impairment

Unmet Need for Care

1. Eating

0

1

2

3

0

1

2

3

2. Bathing

0

1

2

3

0

1

2

3

3. Grooming

0

1

2

3

0

1

2

3

4. Dressing

0

1

2

3

0

1

2

3

5. Transferring

0

1

2

3

0

1

2

3

6. Continence

0

1

2

3

0

1

2

3

7. Managing Money

0

1

2

3

0

1

2

3

8. Telephoning

0

1

2

3

0

1

2

3

9. Preparing Meals

0

1

2

3

0

1

2

3

10. Laundry

0

1

2

3

0

1

2

3

11. Housework

0

1

2

3

0

1

2

3

12. Outside Home

0

1

2

3

0

1

2

3

13. Routine Health

0

1

2

3

0

1

2

3

14. Special Health

0

1

2

3

0

1

2

3

15. Being Alone

0

1

2

3

0

1

2

3

Comments

Box A: Subtotal
Col. A, Items 1-6

Box A

Box B

Box B: Subtotal
Col. B, Items 1-6

Box C: Subtotal
Col. A, Items 7 - 15

Box C

Box D

Box D: Subtotal
Col. B,
Items 7- 15

Box E: Subtotal Box A
and Box C

Box E

Box F

Box F: Subtotal
Box B and
Box D

Box G

Box G: Subtotal
Box E and
Box F

Score:
0

Interpretation:
No Impairment or no unmet need for care

Greater than 1 and less than or
equal to 1.5

Mild impairment or mild unmet need for care

Greater than 1.5 and less than
need for care
or equal to 2

Mild to Moderate impairment or mild to moderate unmet

Greater than 2 and less than or
equal to 2.5

Moderate impairment or moderate unmet need for care

Greater than 2.5

Severe impairment or unmet need for care

114-A-1.3 Overview of Scoring the Impairment Level
Table 1

Impairment Level Score

Score “0” if the client
performs or can perform
all essential components
of the activity, with or
without assistance…
Score “1” if the client
performs or can perform
all essential components
of the activity, with or
without assistance, but
some impairment of
function remains which
requires verbal or physical
assistance in some or all
components of the activity

And If …

-

-

-

no significant impairment level remains;
the activity is not required by the client (refers to
these IADLs only: medication management,
routine health and special health); and/or
the client may benefit from but does not require
verbal or physical assistance
client experiences minor, intermittent fatigue in
performing the activity;
client takes longer than would be required for an
unimpaired person to complete the activity;
client must perform the activity more often than
an unimpaired person; and/or
client requires some verbal prompting to be able
to complete the task.

Score “2” if the client
cannot perform most of
the essential components
of the activity, with or
without assistance, but
some impairment of
function remains which
requires verbal or physical
assistance in some or all
components of the activity

-

Score “3” if the client
cannot perform the
activity and requires
someone else to perform
the task, although s/he
may be able to assist in
small ways; or requires
constant verbal or
physical assistance.

Note: For most people with chronic conditions,
their Functional Impairment scores usually will
increase over time, but may decrease
intermittently with the introduction of a service
or support that results in the person being able
to complete part or all of a task with cueing or
assistance.

-

client experiences frequent or rapid fatigue or
minor exertion in performing the activity;
client takes an excessive amount of time to
perform the activity;
client must perform the activity much more
frequently than an unimpaired person; or
client requires frequent verbal prompting to
complete the task.

Note: A score of “0” in functional impairment will automatically yield a score of “0” for
unmet need.

114-A-1.4 Overview of Scoring Unmet Need for Care
Table 2
Inserted 11/2009: The DON-R score for unmet need for care can fluctuate over time,
depending on the amount of support available to eliminate or reduce unmet need and the
progressive increase in need for assistance, if/when impairment levels increase over time.

Unmet Need for Care
Score

Score “0” , regardless of
the impairment level if
the client’s need for
assistance is met to the
extent that the client is
at no risk to health or
personal safety…

And If …

-

client has no need for assistance; and/or
additional assistance would not benefit the client.

Score “1” if the client’s
need for assistance is
met most of the time…

there is minimal risk to health or personal safety if
additional assistance is not provided.

Score “2” if the client’s
need for assistance is
not met most of the
time….

there is moderate risk to health or personal safety if
additional assistance is not provided

Score “3” if the client’s
need for assistance is
seldom or never met or
there is severe risk to
health and safety….

- the client would require acute medical intervention if
additional assistance is not provided.

Inserted 11/2009:
During the 30-day follow-up period after the implementation of the care plan, the Case
Manager or other responsible staff will review the DON-R assessment scores for impairment
and unmet need for care upon which the care plan is based.
If the services/supports introduced have resulted in an improvement in the consumer’s
ability to perform/complete a task, resulting in a lower “functional impairment score,” staff
will re-score all functional impairment items for which there has been an improvement in
functional capacity or the ability to perform the task.
Example: An elderly person with severe arthritis cannot fully manage the ADL task of
dressing because s/he has difficulty buttoning outerwear (shirts/blouses/slacks), tying
shoes, etc. Providing the person with adaptive clothing items, such as garments with Velcro
closures, and slip-on shoes or shoes with Velcro closings now enables the person to
complete the tasks of dressing. Although the person still has a disabling condition, the
accommodation of adaptive clothing has reduced or eliminated the inability to complete the
tasks associated with the ADL for dressing. Staff will rescore this item to reflect the change
in ability to perform the task at this point in time and enter the revised DON into AIMS.
Original Functional Impairment Score for Dressing ADL = 2
Follow-up Functional Impairment Score = 0
A frail elderly person does not bathe independently because she cannot enter
Example:
and exit the bathtub/shower safely. She does not bathe regularly and as a result suffers
from very poor hygiene, with skin integrity being compromised. After grab bars and nonslip strips are installed on the bathroom walls and in the bath/shower enclosure, and a bath
seat is provided, she can now use the shower to bathe regularly. Her hygiene improves, but
because she cannot completely dry herself due to limitations in range of motion, skin
integrity still may be an issue.
Original Functional Impairment Score for Bathing ADL = 3
Follow-up Functional Impairment Score = 1
If the services/supports introduced have eliminated or reduced the unmet need for care,
staff will re-score all items for which need for care is now being met, including partially met,
if the new score is lower than the previous score.
A person who is unable to prepare meals and has no assistance in preparing
Example:
meals, now has a homemaker who prepares and/or provides all meals.
Original “Unmet Need” Score for the IADL of Meal Preparation = 3.
Follow-up “Unmet Need” Score = 0.
A person who is unable to prepare meals and has no assistance in preparing
Example:
meals, now receives a Home Delivered Meal for lunch five days a week, but still needs
breakfast, evening and weekend meals.
Original “Unmet Need” Score for the IADL of Meal Preparation = 3.
Follow-up “Unmet Need” Score = 2.
All changes in scoring are documented by completing a follow-up DON-R in AIMS.
In-depth training is available upon request to the Division.

114-A-2 The Nutrition Screening Initiative DETERMINE Checklist
The Nutrition Screening Initiative (NSI) Checklist is a scored checklist aimed at developing
the nutritional awareness of older adults living in the community. The checklist was
developed to be either self-administered by the older adult, or used by professionals to rate
the potential or actual nutrition risk status. The Checklist has been psychometrically tested
and found to have acceptable levels of reliability and validity. The checklist does not
provide a clinical diagnosis but does provide an effective initial screen of nutrition risk. It
has also proven to be an excellent indicator of chronic depression, since depression has a
major impact on nutrition status and chronic disease. Often, people who score high on the
checklist have multiple problems, which can be addressed once identified.
The Nutrition Screening Initiative is a project of the American Academy of Family
Physicians, The American Dietetic Association and the National Council on the Aging.
Following is a summary of the instrument.

NSI-DETERMINE Checklist

YES

I have an illness or condition that made me change the kind and/or
amount of food I eat.

2

I eat fewer than 2 meals per day.

3

I eat few fruits or vegetables.

1

I eat few milk products.

1

I have 3 or more drinks of beer, liquor or wine almost every day.

2

I have tooth or mouth problems that make it hard for me to eat.

2

I don’t always have enough money to buy the food I need.

4

I eat alone most of the time.

1

I take 3 or more prescribed or over-the-counter drugs a day.

1

Without wanting to, I have lost or gained 10 pounds in the last 6
months.

2

I am not always physically able to shop, cook and/or feed myself.

2

Revised
11/2009

Scoring
0-2

Good; not at risk.

Recheck in 6-12 months.

3-5

Moderate risk. Recheck in 6-12 months.

+
High risk. Refer for Level I/II screening and to health care
6
professional.

Revised
11/2009

TOTAL

For additional information on planning interventions using the NSI Checklist and related
materials, refer to The Nutrition Interventions Manual for Professionals Caring for Older
Americans, 1992, Greer, Margolis, Mitchell, Grunwald and Associates, for the Nutrition

Screening Initiative, 2626 Pennsylvania Avenue, N.W., Suite 301, Washington, D.C., 20037,
or visit websites at http://www.aafp.org/x16081.xml and
http://www.eatright.org/images/nsifinal.pdf

Appendix 114-B
Process Flow for Coordination of HCBS Assessment

Referral to Gateway
for
Intake/Screening/
Referral

HCB Services
Needed?

No

Continue to assist
applicant with
I&A services or
CCSP Screening

Yes

HCB Services
available now?

No
Place applicant on
waiting list

Assist applicant
with referrals to
other resources
while waitlisted

Yes

Is applicant
current CCSP
client?

Yes

Contact CCSP Care
Coordinator

No

Is HCBS Case
Management
available?

Yes

Refer to HCBS Case
Management Agency
for full assessment

No

Refer to HCBS
Provider Agency* for
assessment

*If 2 or more HCBS providers
are involved, AAA designates primary
provider to conduct all assessments.

Appendix 114-C
Determination of Need Functional Assessment Instrument
Instruction Manual

DETERMINATION OF NEED FUNCTIONAL ASSESSMENT INSTRUMENT
INSTRUCTION MANUAL

DETERMINATION OF NEED FUNCTIONAL ASSESSMENT INSTRUMENT
INSTRUCTION MANUAL

TABLE OF CONTENTS
Definitions ..................................................................................................................................... ii
Functional Assessment (ADLs/IADLs) .....................................................................................1
Introduction .......................................................................................................................1
Determination of Need (DON) Functional Assessment Instrument .....................................2
Column A: Level of Impairment ....................................................................................5
Column B: Unmet Need for Care ..................................................................................6
Item Definitions .................................................................................................................7
Scoring the DON .........................................................................................................................13
Interpretation of The DON ........................................................................................................14
References ....................................................................................................................................15

(Revised Manual:June 30, 1995)

i

DEFINITIONS:
There are a few terms used throughout the DON manual that require a definition.

CLIENT

Persons who are undergoing an assessment for the particular program or
agency by which you are employed.

ASSESSOR

The person conducting the assessment.

CAREGIVERS

Caregivers are individuals who provide informal physical, emotional and
cognitive supports. They are usually unpaid family members or friends
who provide care for the applicant.

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ii

FUNCTIONAL ASSESSMENT (ADLs/IADLs)
INTRODUCTION
The Determination of Need Functional Assessment (DON) instrument was originally
developed as part of a contract with the Illinois Department of Aging to provide it with the
means for determining eligibility for community based services. As such there was a need for
the DON to identify those factors that were the best predictors of need for care. Furthermore,
there was a need for the instrument to be constructed in a fashion that would permit the state to
set funding caps for different levels of impairment, but also allow for adjustment as a carerecipient’s care needs changed. Beginning in 1987 and concluding in 1989, a group of
researchers at the Gerontology Center of the University of Illinois at Chicago, worked on
developing such an instrument. The process involved in the DON’s development is well
documented in a three volume final report to the Illinois Department on Aging (Paveza et al.,
1989; Prohaska et al., 1989; Hagopian et al., 1990) and in two articles (Paveza et al., 1990a;
Paveza et al., 1990b).
Since the DON was developed as part of a state contract the instrument resides in the
public domain. The instrument described in this manual represents a modification for use by
those wishing to solely assess functional impairment in persons with whom they are working, as
well as refinements made to the interpretative process as use of this instrument has evolved over
time. Nevertheless, since the original DON was developed under a public contract, this modified
DON also resides in the public domain.
The Determination of Need (DON) defines the factors which help determine a person’s
functional capacity and their unmet need for assistance in dealing with these impairments. The
DON allows for independent assessment of both impairment in functioning on Basic Activities
of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) and the need for
assistance to compensate for these impairments.
The backbone of determining the level of need for care is whether a person can perform
activities of daily living (ADL). Table 1 presents the list of ADL included in the DON under
two headings: BASIC AND INSTRUMENTAL.

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1

Basic Activities of Daily Living
(BADL)

Instrumental Activities of Daily Living
(IADL)

Eating

Managing Money

Bathing

Telephoning

Grooming

Preparing Meals

Dressing

Laundry

Transfer (In & Out of Bed/Chair)

Housework

Bowel/Bladder Continence

Outside Home
Routine Health
Special Health
Being Alone

Basic Activities of Daily Living (BADL) refer to those activities and behaviors that are
the most fundamental self-care activities to perform and are an indication of whether the person
can care for ones own physical needs.
Instrumental Activities of Daily Living (IADL) are the more complex activities
associated with daily life. (They are applications of the Basic Activities of Daily Living.)
Information regarding both BADL and IADL are essential to evaluating whether a person can
live independently in the community.
DETERMINATION OF NEED (DON) FUNCTIONAL ASSESSMENT INSTRUMENT
The Determination of Need (DON) Functional Assessment is a unique measure of
functional assessment in that it differentiates between impairment in functional capacity and the
need for care around a particular functional capacity. Furthermore, it is an ordinal scale with
clearly defined meanings for each level of impairment, each level of unmet need for care and
each functional activity. Because of its ordinal nature, it permits quantification of scores so that
changes in scores in subscales for BADLs and IADL’s and for Total Impairment represent actual
changes in impairment, and changes in scores for unmet need for care in BADLs, IADLs and
Total Unmet Need for Care represent actual changes in unmet need for care. Table 2 presents
the instrument in reduced format, a copy of the actual instrument for use is included at the end of
this manual.
Before discussing the specific definitions that describe the functional activities included
in the DON and the definitions that specify each of the levels of impairment and unmet need for
care, some general comments about the DON are provided to assist in the completion of the
instrument.

(Revised Manual:June 30, 1995)

2

THE "CASE COMMENTS" SPACE TO THE RIGHT OF COLUMN B IN THE
FUNCTIONAL STATUS SECTION IS USED TO:


Note special reasons for impairment or unmet need.
Describe the type of service, caregiver support or assistive devices that decreases the
client's unmet need.
Record the primary caregivers’ names or other pertinent information.

COLUMN RULES:
Use the following criteria to decide when to stop asking questions for a particular Functional
Status item or when to skip column B.
1)

Ask each FUNCTIONAL STATUS item, starting with Column A.

2)

If Column A, "level of impairment”, is scored “0", score Column B “0".

3)

If Column A is scored greater than “0", ask Column B.

(Revised Manual:June 30, 1995)

3

DETERMINATION OF NEED FUNCTIONAL ASSESSMENT
Case Comments: Identify resources, describe special
needs and circumstances that should be taken into
account when developing a care plan

Function

Level of
Impairment

Unmet Need
for Care

1. Eating

0 1 2 3

0 1 2 3

2. Bathing

0 1 2 3

0 1 2 3

3. Grooming

0 1 2 3

0 1 2 3

4. Dressing

0 1 2 3

0 1 2 3

5. Transferring

0 1 2 3

0 1 2 3

6. Continence

0 1 2 3

0 1 2 3

7. Managing Money

0 1 2 3

0 1 2 3

8. Telephoning

0 1 2 3

0 1 2 3

9. Preparing Meals

0 1 2 3

0 1 2 3

10. Laundry

0 1 2 3

0 1 2 3

11. Housework

0 1 2 3

0 1 2 3

12. Outside Home

0 1 2 3

0 1 2 3

13. Routine Health

0 1 2 3

0 1 2 3

14. Special Health

0 1 2 3

0 1 2 3

15. Being Alone

0 1 2 3

0 1 2 3

Box A: Subtotal Col A, Items 1-6

Box A

Box B

Box B: Subtotal Col B, Items 1-6

Box C: Subtotal Col A., Items 7 15

Box C

Box D

Box D: Subtotal Col B, Items 7 - 15

Box E: Subtotal Box A & Box C

Box E

Box F

Box F: Subtotal Box B & Box D

Box G

Box G: Subtotal Box E & Box F

COLUMN A: LEVEL OF IMPAIRMENT
Each one of the basic and instrumental activities of daily living (BADL/IADL) needs to
be discussed in terms of level of impairment. How the assessor mentions functional impairment
is not as important as encouraging the client to report difficulties with the activity. Sample
questions could include:
Are you able to do . . . ?
(Revised Manual:June 30, 1995)

4

How much difficulty do you have in doing . . . ?
The object is to gather sufficient information to determine the most appropriate score below.
Score 0 - Performs or can perform all essential components of the activity, with or without an
assistive device, such that:


no significant impairment of function remains; or
activity is not required by the client (IADLs: medication management, routine and special
health only); or
client may benefit from but does not require verbal or physical assistance.

Score 1 - Performs or can perform most essential components of the activity with or without an
assistive device, but some impairment of function remains such that client requires some verbal
or physical assistance in some or all components of the activity.
This includes clients who:



experience minor, intermittent fatigue in performing the activity; or
take longer than would be required for an unimpaired person to complete the activity; or
must perform the activity more often than an unimpaired person; or
require some verbal prompting to complete the task.

Score 2 - Cannot perform most of the essential components of the activity, even with an assistive
device, and/or requires a great deal of verbal or physical assistance to accomplish the activity.
This includes clients who:



experience frequent fatigue or minor exertion in performing the activity; or
take an excessive amount of time to perform the activity; or
must perform the activity much more frequently than an unimpaired person; or
require frequent verbal prompting to complete the task.

Score 3 - Cannot perform the activity and requires someone else to perform the task, although
client may be able to assist in small ways; or requires constant verbal or physical assistance.

COLUMN B: UNMET NEED FOR CARE
In scoring this column, the idea is both to obtain information from the client about their
perceptions regarding need for care and to use your observational skills to determine what the
impact might be on the client should care or assistance not be provided to the client. The
availability of an appropriate caregiver also needs to be assessed.

(Revised Manual:June 30, 1995)

5

Questions that might be asked of clients and caregivers are:
Can you tell me if you are getting enough help in meeting your needs around _?
Do you think you need more help with _?
In your own observations, look at client’s mobility, level of clutter, appearance, unpaid
bills, forgetfulness, etc., to assess the level of risk to health or safety if current levels of
assistance are not maintained, or if additional assistance is not added.
Score 0 - The client's need for assistance is met to the extent that the client is at no risk to health
or safety if additional assistance is not acquired; or the client has no need for assistance; or
additional assistance will not benefit the client.
Score 1 - The client's need for assistance is met most of the time, or there is minimal risk to the
health and safety of the client if additional assistance is not acquired.
Score 2 - The client's need for assistance is not met most of the time; or there is moderate risk to
the health and safety of the client if additional assistance is not acquired.
Score 3 - The client's need for assistance is seldom or never met; or there is severe risk to the
health and safety of the client that would require acute medical intervention if additional
assistance is not acquired.
ITEM DEFINITIONS

1.

EATING

A.

IS THE CLIENT ABLE TO FEED HIMSELF/HERSELF?

Assess the client's ability to feed oneself a meal using routine or adapted table utensils
and without frequent spills. Include the client's ability to chew, swallow, cut food into
manageable size pieces, and to chew and swallow hot and cold foods/beverages. When a special
diet is needed, do not consider the preparation of the special diet when scoring this item (see
“preparing meals” and “routine health” items).
B.

IS SOMEONE AVAILABLE TO ASSIST THE CLIENT AT MEALTIME?

If the client scores at least one (1) in Column A, evaluate whether someone (including
telephone reassurance) is available to assist or motivate the client in eating.

(Revised Manual:June 30, 1995)

6

2.

BATHING

A.

IS THE CLIENT ABLE TO SHOWER OR BATHE OR TAKE SPONGE BATHS FOR THE PURPOSE OF
MAINTAINING ADEQUATE HYGIENE AS NEEDED FOR THE CLIENT’S CIRCUMSTANCES?

Assess the client's ability to shower or bathe or take sponge baths for the purpose of
maintaining adequate hygiene. Consider minimum hygiene standards, medical prescription, or
health related considerations such as incontinence, skin ulcer, lesions, and frequent profuse nose
bleeds. Consider ability to get in and out of the tub or shower, to turn faucets, regulate water
temperature, wash and dry fully. Include douches if required by impairment.
B.

IS SOMEONE AVAILABLE TO ASSIST OR SUPERVISE THE CLIENT IN BATHING?

If the client scores at least one (1) in Column A, evaluate the continued availability of
resources to assist in bathing. If intimate assistance is available but inappropriate and/or opposed
by the client, consider the assistance unavailable.
3.

GROOMING

A.

IS THE CLIENT ABLE TO TAKE CARE OF HIS/HER PERSONAL APPEARANCE?

Assess client's ability to take care of personal appearance, grooming, and hygiene
activities. Only consider shaving, nail care, hair care, and dental hygiene.
B.
IS SOMEONE AVAILABLE TO ASSIST THE CLIENT IN PERSONAL GROOMING TASKS?
If the client scores at least one (1) in Column A, evaluate the continued personal
assistance needed, including health professionals, to assist the client in grooming.

4.

DRESSING

A.

IS THE CLIENT ABLE TO DRESS AND UNDRESS AS NECESSARY TO CARRY OUT OTHER
ACTIVITIES OF DAILY LIVING?

Assess the client's ability to dress and undress as necessary to carry out the client's
activities of daily living in terms of appropriate dress for weather or street attire as needed. Also
include ability to put on prostheses or assistive devices. Consider fine motor coordination for
buttons and zippers, and strength for undergarments or winter coat. Do not include style or color
coordination.
B.

IS SOMEONE AVAILABLE TO ASSIST THE CLIENT IN DRESSING AND UNDRESSING?

If the client scores at least one (1) in Column A, evaluate whether someone is available to
help dressing and/or undressing the client at the times needed by the client. If intimate assistance
is available but inappropriate and/or opposed by the client, consider the assistance unavailable.
(Revised Manual:June 30, 1995)

7

5.

TRANSFER

A.

IS THE CLIENT ABLE TO GET INTO AND OUT OF BED OR OTHER USUAL SLEEPING PLACE?

Assess the client's ability to get into and out of bed or other usual sleeping place,
including pallet or arm chair. Include the ability to reach assistive devices and appliances
necessary to ambulate, and the ability to transfer (from/to) between bed and wheelchair, walker,
etc. Include ability to adjust the bed or place/remove handrails, if applicable and necessary.
When scoring, do not consider putting on prostheses or assistive devices.
B.

IS SOMEONE AVAILABLE TO ASSIST OR MOTIVATE THE CLIENT TO GET IN AND OUT OF BED?

If the client scores at least one (1) in Column A, evaluate the continued availability of
resources, (including telephone reassurance and friendly visiting) to assist or motivate the client
in getting into and out of bed.
6.

CONTINENCE

A.

IS THE CLIENT ABLE TO TAKE CARE OF BLADDER/BOWEL FUNCTIONS WITHOUT DIFFICULTY?

Assess the client's ability to take care of bladder/bowel functions by reaching the
bathroom or other appropriate facility in a timely manner. Consider the need for reminders.
B.

IS SOMEONE AVAILABLE TO ASSIST THE CLIENT IN PERFORMING BLADDER/BOWEL
FUNCTIONS?

If the client scores at least one (1) in Column A, evaluate whether someone is available to
assist or remind the client as needed in bladder/bowel functions.
7.

MANAGING MONEY

A.

IS THE CLIENT ABLE TO HANDLE MONEY AND PAY BILLS?

Assess the client's ability to handle money and pay bills. Include ability to plan, budget,
write checks or money orders, exchange currency, and handle paper work and coins. Include the
ability to read, write and count sufficiently to perform the activity. Do not increase the score
based on insufficient funds.

(Revised Manual:June 30, 1995)

8

B.

IS SOMEONE AVAILABLE TO HELP THE CLIENT WITH MONEY MANAGEMENT AND MONEY
TRANSACTIONS?
If the client scores at least one (1) in Column A, evaluate whether an appropriate person
is available to plan and budget or make deposits and payments on behalf of the client. Consider
automatic deposits, banking by mail, etc.
8.

TELEPHONING

A.

IS THE CLIENT ABLE TO USE THE TELEPHONE TO COMMUNICATE ESSENTIAL NEEDS?

Assess the client's ability to use a telephone to communicate essential needs. The client
must be able to use the phone: answer, dial, articulate and comprehend. If the client uses special
adaptive telephone equipment, score the client based on the ability to perform this activity with
that equipment. Do not consider the absence of a telephone in the client's home. (Note: The use
of an emergency response system device should not be considered)
B.

IS SOMEONE AVAILABLE TO ASSIST THE CLIENT WITH TELEPHONE USE?

If the client scores at least one (1) in Column A, evaluate whether someone is available to
help the client reach and use the telephone or whether someone is available to use the telephone
on behalf of the client. Consider the reliability and the availability of neighbors to accept
essential routine calls and to call authorities in an emergency.
9.

PREPARING MEALS

A.

IS THE CLIENT ABLE TO PREPARE HOT AND,/OR COLD MEALS THAT ARE NUTRITIONALLY
BALANCED OR THERAPEUTIC, AS NECESSARY, WHICH THE CLIENT CAN EAT?

Assess the client's ability to plan and prepare routine hot and/or cold, nutritionally
balanced meals. Include ability to prepare foodstuffs, to open containers, to use kitchen
appliances, and to clean up after the meal, including washing, drying and storing dishes and other
utensils used in meal preparation. Do not consider the ability to plan therapeutic or prescribed
meals.
B.

IS SOMEONE AVAILABLE TO PREPARE MEALS AS NEEDED BY THE CLIENT?

If the client scores at least one (1) in Column A, evaluate the continued availability of
resources (including restaurants and home-delivered meals) to prepare meals or supervise meal
preparation for the Client. Consider whether the resources can be called upon to prepare meals
in advance for reheating later.
10.

LAUNDRY

A.

IS THE CLIENT ABLE TO DO HIS,/HER LAUNDRY?

(Revised Manual:June 30, 1995)

9

Assess the client's ability to do laundry including sorting, carrying, loading, unloading,
folding, and putting away. Include use of coins where needed and use of machines and/or sinks.
Do not consider the location of the laundry facilities.
B.

IS SOMEONE AVAILABLE TO ASSIST WITH PERFORMING OR SUPERVISING THE LAUNDRY
NEEDS OF THE CLIENT?

If the client scores at least one (1) in Column A, evaluate the continued availability of
laundry assistance, including washing and/or dry cleaning. If public laundries are used, consider
the reliability of others to insert coins, transfer loads, etc.
11.

HOUSEWORK

A.

IS THE CLIENT ABLE TO DO ROUTINE HOUSEWORK?

Assess the client's ability to do routine housework. Include sweeping, scrubbing, and
vacuuming floors. Include dusting, cleaning up spills, and cleaning sinks, toilets, bathtubs.
Minimum hygienic conditions for client's health and safety are required. Do not include laundry,
washing or drying dishes or the refusal to do tasks if refusal is unrelated to the impairment.
B.

IS SOMEONE AVAILABLE TO SUPERVISE, ASSIST WITH, OR PERFORM ROUTINE HOUSEHOLD
TASKS FOR THE CLIENT AS NEEDED TO MEET MINIMUM HEALTH AND HYGIENE STANDARDS?

If the client scores at least a one (1) in Column A, evaluate the continued availability of
resources, including private pay household assistance and family available to maintain the
client's living space. When the client lives with others, do not assume the others will clean up
for the client. This item measures only those needs related to maintaining the client's living
space and is not to measure the maintenance needs of living space occupied by others in the
same residence.
12.

OUTSIDE HOME

A.

IS THE CLIENT ABLE TO GET OUT OF HIS/HER HOME AND TO ESSENTIAL PLACES OUTSIDE THE
HOME?

Assess the client's ability to get to and from essential places outside the home. Essential
places may include bank, post office, mail box, medical offices, stores, and laundry if nearest
available facilities are outside the home. Consider ability to negotiate stairs, streets, porches,
sidewalks, entrance and exits of residence, vehicle, and destination in all types of weather.
Consider the ability to secure appropriate and available transportation and to know locations of
home and essential places. Lack of appropriate and available transportation as needed, will
increase the score. However, in scoring, do not consider the inability to afford public
transportation.

(Revised Manual:June 30, 1995)

10

B.

IS SOMEONE AVAILABLE TO ASSIST THE CLIENT IN REACHING NEEDED DESTINATIONS?

If the client scores at least one (1) in Column A, evaluate the continued availability of
escort and transportation, or someone to go out on behalf of the client. Consider banking by
mail, delivery services, changing laundromats, etc., to make destinations more accessible.

13.

ROUTINE HEALTH CARE

A.

IS THE CLIENT ABLE TO FOLLOW THE DIRECTIONS OF PHYSICIANS, NURSES OR THERAPISTS,
AS NEEDED FOR ROUTINE HEALTH CARE?

Assess the client's ability to follow directions from a physician, nurse or therapist, and to
manipulate equipment in the performance of routine health care. Include simple dressings,
special diet planning, monitoring of symptoms and vital signs (e.g. blood pressure, pulse,
temperature and weight), routine medications, routine posturing and exercise not requiring
services or supervision of a physical therapist.
B.

IS SOMEONE AVAILABLE TO CARRY OUT OR SUPERVISE ROUTINE MEDICAL DIRECTIONS OF
THE CLIENT'S PHYSICIAN OR OTHER HEALTH CARE PROFESSIONALS?

If the client scores at least one (1) in Column A, evaluate the continued availability of
someone to remind, supervise or assist the client in complying with routine medical directions.
If the assistance needed involves intimate care, and the caregiver is inappropriate and,/or
opposed by the client, consider the assistance unavailable.

14.

SPECIAL HEALTH CARE

A.

IS THE CLIENT ABLE TO FOLLOW DIRECTIONS OF PHYSICIANS, NURSES OR THERAPISTS AS
NEEDED FOR SPECIALIZED HEALTH CARE?

Assess the client's ability to perform or assist in the performance of specialized health
care tasks which are prescribed and generally performed by licensed personnel including
physicians, nurses, and therapists. Include blood chemistry and urinalysis; complex catheter and
ostomy care; complex or non-routine posturing/suctioning; tube feeding; complex dressings and
decubitus care; physical, occupational and speech therapy; intravenous care; respiratory therapy;
or other prescribed health care provided by a licensed professional. Score "O" for clients who
have no specialized health care needs.
B.

IS SOMEONE AVAILABLE TO ASSIST WITH OR PROVIDE SPECIALIZED HEALTH CARE FOR THE
CLIENT?

(Revised Manual:June 30, 1995)

11

If the client scores at least one (1) in Column A, evaluate the continued availability of
specially trained resources as necessary to assist with or perform the specialized health care task
required by the client.
15.

BEING ALONE

A.

CAN THE CLIENT BE LEFT ALONE?

Assess the client's ability to be left alone and to recognize, avoid, and respond to danger
and/or emergencies. Include the client's ability to evacuate the premises or alert others to the
Client's need for assistance, if applicable, and to use appropriate judgment regarding personal
health and safety.
B.

IS SOMEONE AVAILABLE TO ASSIST OR SUPERVISE THE CLIENT WHEN THE CLIENT CANNOT
BE LEFT ALONE?

If the client scores at least one (1) in Column A, evaluate the continued availability of
someone to assist or supervise the client as needed to avoid danger and respond to emergencies.
Consider friendly visiting, telephone reassurance, and neighborhood watch programs.

SCORING THE DON
Scoring the DON is done by obtaining a series of totals in boxes A, B, C, D, E, F, and G on
the bottom of the DON form.
SUBTOTALS OF COLUMNS A AND B:
1.

Add the scores for the first six functional activities (1-6) of Column A, and enter
that score in Box A (SUM [1 - 6] = Box A). Then add the scores for the last nine
functional activities (7-15) and enter that score in Box C (SUM [7 - 15] = Box C).
Finally add the scores for Box A and Box C and place that total in Box E (Box A
+ Box C = Box E).

2.

Add the scores for the first six functional activities (1-6) of Column B, and enter
that score in Box B (SUM [1 - 6] = Box B). Then add the scores for the last nine
functional activities (7-15) of Column B and enter that score in Box D (SUM [7 15] = Box D). Finally add the scores for Box B and Box D and place that total in
Box F (Box B + Box D = Box F)

3.

Add the scores from Box E and Box F and enter that total in Box G (Box E + Box
F = Box G).

Each of these boxes provides specific information about the client. Box A provides a
score that represents total impairment in Basic Activities of Daily Living, while Box C provides
(Revised Manual:June 30, 1995)

12

a score that represents total impairment in Instrumental Activities of Daily Living. Box E
provides a summary score that represents total functional impairment.
Box B provides a score that represents the total unmet need for care in Basic Activities of
Daily Living, while Box D provides information about the total unmet need for care around
Instrumental Activities of Daily Living. Box F provides a summary score of unmet need for all
Activities of Daily Living.
Box G provides a summary score that represents a total care burden and represents both a
combination of total impairment and total unmet need for care.

INTERPRETATION OF THE DON
Interpretation of the DON should be considered in light of several factors including the
degree to which scores are a mix between no impairment and moderate and severe impairment.
However, by dividing the score entered in any Box by the number of activities that make up its
subscale score, it is possible to reduce that score to an ordinal equivalent, a category between No
Impairment and Severe Impairment. To derive standardized scores for each box: Divide Box A
and Box B by 6; Divide Box C and Box D by 9; Divide Box E and Box F by 15; and divide
Box G by 30. This will provide you with a score between 0 and 3, which can then be matched to
the interpretations offered below for the standardized scores. Remember that to use these
interpretations you must divide the score in any box by the numbers noted above (6,9,15 or
30).

Score

Interpretation

0

No impairment or no unmet need for care

Greater than 0 and
less than or equal to 1

Mild impairment or mild unmet need for care

Greater than 1 and
less than or equal to 1.5

Mild to Moderate impairment or mild to moderate unmet need for
care

Greater than 1.5 and
less than or equal to 2

Moderate impairment or moderate unmet need for care

Greater than 2 and less
than or equal to 2.5

Moderate to severe impairment or unmet need for care

Greater than 2.5

Severe impairment or unmet need for care

(Revised Manual:June 30, 1995)

13

To make a specific interpretation, choose one of the boxes and divide that score by the
appropriate number as indicated on page 14. Then interpret that modified score based on the
functional activities or unmet need for care represented by that box. For example if discussing
the modified Box A score, a score of 1.7 would be interpreted to mean that the client has mild to
moderate impairment in Basic Activities of Daily Living, while this same score for box C would
be interpreted to mean mild to moderate impairment in Instrumental Activities of Daily Living.
In Box D, it would be interpreted to mean mild to moderate unmet need for care. Finally in Box
G this score would be interpreted to mean mild to moderate overall care burden in functional
activities.
Reporting can than be enhanced by noting the specific areas of impairment. Thus one
might report that: “Mrs. Jones is moderately impaired in BADL’s with specific impairments in
Bathing, Dressing and Transfer. She has a moderate unmet need for care in BADL’s with
specific needs in Bathing and Transfer.” Similar specificity can be applied to IADL’s, total
functional capacity and total care burden.
REFERENCES
Hagopian M, Paveza GJ, Prohaska T, Cohen D: Determination of Need - Revision Final Report,
Volume III. Chicago, Illinois: University of Illinois at Chicago, 1990.
Paveza GJ, Cohen D, Hagopian M, Prohaska T, Blaser CJ, Brauner D: A Brief Assessment
Tool for Determining Eligibility and Need for Community Based Long Term Care
Services. Behavior, Health and Aging 1: 121-132, 1990a.

(Revised Manual:June 30, 1995)

14

Paveza GJ, Cohen D, Blaser CJ, Hagopian M: A Brief Form of the Mini-Mental State
Examination for Use in Community Settings. Behavior, Health and Aging 1: 133-139,
1990b.
Paveza GJ, Prohaska T, Hagopian M, Cohen D: Determination of Need - Revision: Final
Report, Volume I. Chicago, Illinois: University of Illinois at Chicago, 1989.
Prohaska T, Hagopian M, Cohen D, Paveza GJ: Determination of Need - Revision Final Report,
Volume II. Chicago, Illinois: University of Illinois at Chicago, 1989.