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3. Section G and SPG Expansion

Section G and the SPG tool of the InterRAI are used to evaluate the participant’s capabilities and needs in order to determine the amount of caregiver assistance the participant needs each week. 

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Section G: Functional Status

Used to “score” the level of dependence each participant has for their individual ADLs and IADLs. 

IADLs – Instrumental Activities of Daily Living

Self-care tasks that are necessary to live independently in the world. If these activities are not performed, it would result in a risk to a participant’s ability to live independently.

IADL Tasks
TaskDetails
Meal Preparation-How meals are prepared
-Includes: Planning/Deciding what food will be made for each meal, Preparing ingredients, Actually cooking and using appliances, setting up the dishes and utensils
Ordinary Housework– How ordinary work around the house is performed
– Includes: doing dishes, tidying up, dusting, vacuuming, making the bed, laundry, cleaning the bathroom.
Managing Finances– How bills are paid, checkbook is balanced, household expenses are budgeted, credit card is monitored
Medication Management– How telephone calls are made or received
– Includes: remembering to take medications, opening bottles, taking correct drug dosages, giving injections, and applying ointments
Phone Use– How telephone calls are made or received
Includes: assistance using assistive devices with phone use
Stairs– How going up and down full flight of stairs is managed
Shopping– How shopping is performed for food and household items
– Includes: knowing what items are needed, choosing items, grabbing items and putting them in a cart, pushing a cart, paying money, bagging and carrying items.
– EXCLUDE TRANSPORTATION
Transportation– How participant travels by public transportation or drives themselves
– Includes: navigating the public transit system, paying money for fares, getting in and out of the house and vehicles.
IADL scoring

IADLs are scored separately based on Performance and Capacity

  • Performance – the summation of actual performance of the task for the past 3 days. 
    • There is no speculation on the client’s or participant’s part. It is what was actually done. 
  • Capacity – the presumed capability of the participant to complete the task. 
    • This is gathered from conversation with the participant and caregivers as well as speculation of the participant. If you feel the participant is more or less capable of completing a task than was given in the performance, then the capacity score should reflect it!

Scores

ScoreDescriptionExample
0Independent
No help, setup, or supervision

Meaning the participant does not need any assistance at all with the task.
Ex. The participant states they don’t need any assistance making or receiving calls
1Setup Help Only
The participant needs someone to set up all the necessary tools to complete the task, but then they can do the task without assistance.
Ex. The participant needs her daughter to get all bills and finances together, but once it is together the participant does the work themselves.
2Supervision
The participant needs someone to watch over them and make sure they do the task correctly, but still do all parts of the task themselves. 
Ex. The participant needs their caregiver to remind the participant and make sure they take their medications, but they organize and take them by themselves.
3Limited Assistance
The participant can do the task themselves sometimes, but other times they need assistance.
Ex. The participant is able to make themselves a bowl of cereal or a sandwich, but needs assistance with more involved meals.
4Extensive Assistance
The participant needs assistance every time they complete the task, but are able to do more than half of said task on their own.
Ex. The participant goes shopping with a caregiver or informal support every time they need to go shopping, but they will push the cart, choose items, and pay for it themselves. The caregiver will grab items selected and carry heavy bags
5Maximal Assistance
The participant needs assistance every time they complete the tasks and they do less than 50% of the task themselves
Ex. The participant needs assistance for housework, they are able to use a duster on all reachable surfaces, but the caregiver or informal support does the high surfaces, vacuuming, mopping/sweeping, laundry, etc.
6Total Dependence
The participant has absolutely no involvement in the task. If it weren’t for the caregivers it would not be done. 
Ex. The participant needs someone to take them upstairs, they cannot take any steps themselves and if no one is around they don’t go up or down stairs.
8Activity did not occur
In the past 3 days the task was not done at all. 

This is NOT used when scoring capacity (because capacity is based on some speculation.)
Ex. The participant has not left the house in the past 3 days and therefore did not need transportation anywhere.

ADLs – Activities of Daily Living

Daily tasks that are necessary to remain healthy. If these are not performed it would result in immediate risk to the participant’s health or safety.

ADL – Tasks
TaskDetails
Bathing– How a full bath/shower is taken
– Includes: Transferring in and out of the tub/shower and how each part of the body is washed
Personal Hygiene– How personal hygiene tasks are managed/completed.
– Includes: Transferring in and out of the tub/shower and how each part of the body is washed
Dressing Upper Body– How dressing/undressing above the waist is managed.
– Includes: underwear and outerwear, fastening buttons, zippers, prostheses, orthotics, etc.
Dressing Lower Body– How dressing/undressing from the waist down is managed.
– Includes: underwear and outwear, fastening buttons, zippers, prostheses, orthotics, etc.
Walking– How ambulation from one point to another, on the same floor is managed.
– Includes: getting in and out of a bed, chair, or sofa, walking with or without assistive devices from one point to another while on the same floor.
-Note: the only time you should say “this activity did not occur” if the participant strictly uses a wheelchair or is bed bound
Locomotion– How the use of durable medical equipment for ambulation (including wheelchairs) is managed on the same floor.
– Includes: ambulation with a cane, walker, wheelchair, etc; getting in and out of a bed, chair, or sofa with assistance device, walking with an assistive device from one point to another while on the same floor, being reminded to use assistive devices.
– Note: the only time you should say “this activity did not occur” is if the participant does not use any assistive devices or if the participant is bed bound.
Transfer Toilet– How they move on and off the toilet or commode.
– Note: This is just for getting on and off of a toilet or commode. If the ptp is completely incontinent and does not use a toilet or commode, then this activity does not occur.
Toilet Use– How using the toilet/commode/incontinence supplies is managed.
– Includes: cleansing themselves after going to the bathroom, either the toilet/commode or incontinence supplies, changing pads/diapers or other incontinence supplies, manages ostomy’s and/or catheters, readjusting clothes after going to the bathroom.
Bed Mobility– How movement in bed is managed.
– Includes: assistance moving from a lying position to sitting upright and vice versa, turning from side to side in the bed, changing positions in bed.
Eating– How eating and drinking is managed
– Includes: intake of food by other means such as tube feeding.
– Note: It is NOT about set up of the meal, that is included in Meal Prep
ADL scoring

ADLs are only scored on performance of the last 3 days

  • If every single time the activity occurred was at the same level, then score the task at that level.
    • Ex. If the participant says every time they take a bath/shower they just needed someone nearby to supervise, then you should give them the score for “Supervision”
  • If any episode in the past 3 days was a 6, and others were less dependent, then score it at 5.
    • Ex. If the participant says “Yesterday I was not able to move around in my bed at all, but today and most other days I can at least readjust myself” then you should give them a score of 5
  • Otherwise, if the participant says their ability to complete tasks has fluctuated a lot in the last 3 days, focus on the 3 most DEPENDENT episodes. If the most dependent episode is a 1, then score it at 1. Otherwise score it 2-5 on the LEAST dependent episode
    • Ex. In the past 3 days the participant has completed personal hygiene 7 times. Once they needed some weight bearing assistance (4), twice they needed limited assistance (3), every other time they needed set-up help (1). 
      • Therefore, focus on the weight bearing and limited assistance episodes. And you will score it on the least dependent of those episodes, limited assistance (3)

Scores

ScoreDescriptionExample
0Independent
No physical assistance, setup, or supervision in any episode

The participant does not need any setup help, supervision, or assistance at any point throughout the task.
Ex. The participant states they are able to feed themselves after all food is prepared and placed in front of them.
1Independent, setup help only
Article or device provided or placed within reach, no physical assistance or supervision in any episode.

The participant needs someone to setup whatever is needed for the task, but then completes the task on their own.
Ex. The participant needs someone to place their hairbrush and toothbrush in reach and then is able to complete the task themselves.
2Supervision
Oversight/cuing

The participant needs someone to watch over them and make sure they do the task correctly, but they still do all parts of the task themselves.
Ex. The participant is able to get a shower/bath themselves, but need someone to watch over them to make sure they wash themselves fully and point out what they may have missed.
3Limited Assistance
Guided maneuvering of limbs, physical guidance without taking weight.

The participant needs some physical assistance completing the task, but no weight bearing assistance.
Ex. The participant needs someone to guide their arms and legs into clothes when getting dressed, but does not need any weight bearing support at all.
4Extensive Assistance
Weight bearing support by 1 person where ptp still performs 50% or more of subtasks.

The participant needs some weight bearing support by only one person when completing the task, but are still able to do 50% or more of the task themselves.
Ex. The participant is able to get up from the couch, needs to lean on the caregiver when walking into another room, but then is able to sit back down on their own.
5Maximal Assistance
The participant needs weight bearing support by 2 or more people OR they need weight bearing support for more than 50% of the task.
Ex. The participant needs someone to move her position in bed. She exerts some force, but heavily relies on caregivers to move her from lying to sitting up, vice versa, and rolling over in bed. 
6Total Dependence
The participant has absolutely no involvement in the task. If it weren’t for the caregivers it would not be done.
Ex. The participant is not able to clean themselves up after incontinence episodes. They will sit in soiled garments until someone is able to change her.
8Activity did not occur
In the past 3 days the task was not done at all.
Ex. The participant does not use any assistive devices when ambulating. They walk on their own or with assistance from others.


SPG Expansion

The SPG tool is used to define the participant’s capabilities of completing ADLs and IADLs as well as stating how much time they need for caregiver assistance

It defines each IADL and ADL stated in Section G. Go through each task to specifically  define what they need caregiver assistance with. This assessment is meant to be Person centered. Therefore you should NEVER assume information

IADLs and ADLs

These are details pertaining to what/how the DCW can assist with each task, and what should be considered when gauging how much time is needed as well as some points that should be answered in the SC Rationale.

Task:Details:Considerations
Meal PreparationAll the steps of preparing all meals:

– planning/choosing what to eat
– preparing ingredients/supplies for cooking
– Cooking and using appliances
– Setting up food/dishes/utensils
– Do they have informal support available? i.e. Do they live with anyone?
– Do they have any specific dietary needs/preferences?
– Do they require any modifications to their food?
– Do they use (or have they used) other services such as HDM?
Ordinary HouseworkLarger household tasks pertaining to safety and cleanliness:

– Dusting/vacuuming
– Mopping
-Laundry
– Cleaning kitchen/bathroom/living areas
– Do they live with anyone? i.e. do they have informal support available?
– Do they have any health diagnoses requiring a cleaner environment?
– What size residence do they live in/which areas of the home are their own private rooms
Managing FinancesAll aspects of managing finances:

– gathering financial document/resources
-logging into and navigating online banking
-balancing checkbooks/budgeting
-Does the participant have any cognitive delays that would risk financial decisions?
-Do they have any Informal support available?
– Do they have a POA or Representative Payee?
Managing Medications-Reminding participants to take medications
– Ensuring the participant does not choke

-IT IS NOT FOR PROVIDING MEDICATION AND/OR ENSURING THE PTP TAKES THE CORRECT MEDICATIONS/DOSES
– How many medications does the participant take (and how often)?
– Do they live with anyone? i.e. Do they have any informal support available?
– Do they use (or have they used) telecare medication dispensers and/or skilled nursing?
Phone UseHow phone calls are made or received. – Do they have any cognitive delays that impact the participant’s ability to comprehend phone calls?
-Do they have any diagnoses leading to lack of expressing themselves or comprehending others?
– What type of device do they use?
– Do they use/require any assistive devices for phone calls?
StairsHow a full flight of stairs are managed

-Going up and down 12-14 stairs at a time
– Do they live in a home with multiple stories?
– Is the participant a high fall risk?
– Does the participant have any cognitive/memory delays that cause them to forget NOT to take the steps?
– Does the participant use (or have they tried to use) alternate accommodations such as Home modifications, DMEs, and/or SMEs?
– How many times per day do they need to use the stairs?
ShoppingHow shopping for food and household items is managed:

– knowing what items are needed.
– choosing items and carrying them/putting them in a cart.
– pushing a cart.
– paying for items.
– bagging and carrying items in/out of building/vehicles
– Does the participant have any specific/hard to find items? i.e. cultural items/spices and ingredients
– Does the participant live with others? i.e Do they have informal support available?
– Are they receiving HDM and may not need as much groceries?
– Do they have/use grocery delivery services available?
TransportationHow the participant manages using public or private transportation:

– Navigating the public transportation system.
– Paying for fares
– Getting in and out of the home and/or vehicles

-IT DOES NOT INCLUDE THE TIME SPENT DRIVING
– Does the participant have multiple obligations to attend outside of the home?
– How frequently does the participant go out and why?
– Does the participant have mobility problems going in and out of the home/vehicle?
– Does the participant have Informal support available?
– Does the participant use other transportation services?
BathingHow a full bath/shower is completed:

– getting in and out of the tub/shower
– Setting up assistive devices for bathing/showering
– Washing each part of the body (except hair and back)
– How many times a day and week do they shower?
– How much time is spent on a single bath/shower?
-What exactly does the HHA do?
– Does the participant have any incontinence diagnoses that require more frequent bathing?
– Does the participant use any assistive devices/have they been offered any?
Personal HygieneCompleting all personal hygiene tasks:

– Combing/brushing hair
– Shaving
– brushing teeth
– applying make-up
– washing/drying face and hands

-Excludes: Bathing/showering
– What tasks are done for personal hygiene?
– How often is personal hygiene completed?
-How much time is spent on personal hygiene each day?
Dressing Upper BodyHow they dress/undress the upper body

– choosing appropriate clothing
– putting on underwear
– pulling clothes over their head and putting arms through the sleeves
– Fastening buttons/zippers
– Does the participant have any diagnoses that limit mobility of the upper body? i.e contractures of the arms, paralysis including the upper body.
– Is the participant able to sit while dressing the upper body?
– Do they have any informal support who can assist?
Dressing Lower BodyHow they dress/undress the lower body

– choosing appropriate clothing
– putting on underwear
– stepping into clothes and pulling them up to the waist (if applicable)
– Fastening buttons/zippers
– Does the participant have any diagnoses that limit mobility of the lower body and/or weight bearing?
– Does the participant have any incontinence diagnoses requiring frequent re-dressing of the lower body?
-Do they have any informal support who can assist?
WalkingHow the participant walks from point A to B on the same floor:

– Completing additional physical/occupational therapy exercises.
-Getting in and out/on and off chairs, sofas, bed, etc.
– Does the participant have any diagnoses that limit mobility (broken leg(s), poor balance, dizziness/vertigo?
– Is the participant a fall risk? If so what level?
– Does the participant use any assistive devices?
– How many times a day is the participant walking around?
– Does the participant use any assistive devices such as a cane or walker?
– Is the participant completing any other physical activity that requires assistance? If so, how often/how much?
LocomotionHow the participant receives assistance with assistive devices when walking or with a wheelchair

-Retrieving/setting up assistive devices
-Reminders about using assistive devices
-Being pushed in a wheelchair
Does the participant have any diagnoses that limit mobility (broken leg(s), poor balance, dizziness/vertigo?
– Is the participant a fall risk? If so what level?
-what assistive devices do they use and what/how do they need assistance with them?
-does the participant have any cognitive delays that causes them to forget to use assistive devices?
Transfer ToiletAssistance getting on and off of a toilet or commode.

– IT IS NOT FOR GOING TO AND FROM THE BATHROOM (that’s walking/locomotion)
-Does the participant use any assistive devices/have they been offered any? i.e Home mod for grab bars, commode, etc.
-Does the participant have any diagnoses that limit mobility when sitting down or getting up from the toilet?
– How many times a day is the participant going to the bathroom?
– does the participant have any diagnoses or medications that cause them to go to the bathroom more frequently?
Toilet UseAssistance using the toilet and/or commode/urinal or management of incontinence supplies

-wiping/cleaning themselves
-changing pads/incontinence supplies
-managing ostomy/catheters
-re-adjusting clothes
– Does the participant have any diagnoses that limit mobility?
– Is the participant overweight which would limit ability to bend over and clean themselves?
-Is the participant incontinent in any way?
– How many times a day is the participant going to the bathroom?
– does the participant have any diagnoses or medications that cause them to go to the bathroom more frequently?
Bed MobilityMoving/changing positions in bed

– moving to and from lying down to sitting up
– moving from side to side in the bed/rolling over
– changing position in the bed
– Is the participant bed bound?
– Does the participant have any diagnoses that limit their mobility?
– How does the HHA assist and how often?
– Does the participant have any cognitive impairments that cause them to forget to stay in bed when they are supposed to?
– Is the participant at high risk for bed sores? i.e. do they have a schedule where they need to be repositioned regularly to decrease this risk?
EatingHow they eat/drink

– includes tube feeding and other means of eating
being fed and supervision to prevent choking

– IT IS NOT FOR SETTING UP FOOD/DISHES (that is for meal prep)
– How often/how many meals do they eat in a day?
– how does the HHA assist with eating?
– Does the participant have any diagnoses that limit their upper body mobility?
– Does the participant have any physical or mental diagnoses that could cause a risk of choking or aspiration?
Additional Notes:
  • Meal Prep – If the participant chooses to not use HDM or other household member for meal prep, that does NOT mean we can increase their PAS hours
  • Housework – If the participant lives with others the HHA is only responsible for cleaning the participant’s private areas of the home. Public area can/should be cleaned by other members of the house.
    • Also, laundry is not a task that takes hours, because other tasks can be done in the meantime (but it is still good to know when/how often laundry is done)
  • Managing Finances – If the participant has a POA and/or representative payee, or the family does the financial management, then you should not be selecting any days for the HHA.
  • Managing Medications – Not all HHAs are authorized/trained to ensure proper dosages are taken and/or how to administer medications. Therefore they are not authorized to assist with this. If the participant is greatly struggling with medication management they need to look into other resources.
    • Such as obtaining blister packs from a pharmacy to make taking medications more manageable.
  • Stairs – If a participant is at such a great risk when going up and down stairs, they should be doing everything possible to NOT use them so much throughout the day. Therefore they really look into other resources, rather than increasing PAS hours.
    • Such as, if they go up and down stairs for the bathroom, have they been offered commodes/urinals to decrease the need to use the stairs?
  • Shopping – If the participant lives with others they are responsible for getting their own items and should provide justification for why they can’t also shop for the participant. The more often they shop in a week, the less amount of time should be spent on each trip.
  • Transportation – HHAs are not chauffeurs, therefore time for transportation does not include the time for the drive. This is why other transportation services are available/preferred.
    • Rationale should also be supported by other sections of the InterRAI.
  • Bathing – Be sure to understand the participant’s schedule for bathing/showering, especially if they do so multiple times a day or for long periods of time.
    • Have other supports been offered, such as grab bars, walk-in showers, shower chairs, etc.?
  • Personal Hygiene – Be sure to understand the participant’s schedule for hygiene, that is SEPARATE from bathing/showering, especially if they do require more time for this task.
  • Dressing upper body – Consider how much time is spent dressing the upper body alone and if the participant can sit while dressing the upper body.
  • Dressing Lower body – Consider how much time is spent dressing the lower body alone and how much weight bearing assistance is needed.
  • Walking – This section is for any type of walking, even if they rely on a cane or a walker (but it is NOT about receiving assistance with using the device, that is for locomotion). It can also include assistance with PT and OT physical exercises (when the therapist is not there.
    • Note: It does not include stairs (that is for the stairs task)
    • Note: Rationale should also be supported by other sections of the InterRAI.
  • Locomotion – This is about what assistance they require while using assistive devices.
    • Note: Additional time added is ONLY for assistance with the devices. You should not be adding an excessive amount of hours for both walking and locomotion.
  • Transfer Toilet – This is only about getting on and off of the toilet or commode. It is not about walking to/from or in/out of the bathroom.
  • Toilet Use – This is about going to the bathroom and cleaning themselves afterward. Especially if the participant is incontinent.
  • Bed Mobility – This is about movement in bed. It is NOT for getting in/out of the bed (that is walking/locomotion).
    • If the participant is bed bound, describe how much assistance/how often they need help to avoid bedsores and such.
  • Eating – This is just about eating. Setting up the food and dishes is involved in meal prep.
SPG Rationale
  • There needs to be a rationale stated for each task.
    • If a client is completely independent with a task then do NOT select any days of the week and state “Participant name is independent with …”
  • Otherwise, if the participant requires HHA assistance be sure to state answers for the following:
    1. Answer all the considerations in the chart above
    2. Answer the following general considerations for all tasks
      • What is the participant able and unable to do for the task?
      • What is limiting the participant?
        • Particularly diagnoses and symptoms
      • Does the participant have any other barriers (such as lack of informal support)
      • How does formal and informal support assist?
        • How often/how much time is spent on the task?
      • Any additional information/specifics
        • Other services that were tried or are inaccessible
        • Specific requirements for the task (diet, religious concerns, health requirements)
Community Integration Support– Some additional time can be added for participants who were recently discharged from a long term care facility/rehab.
– This is a temporary increase in hours as they re-integrate into living independently
Additional Risk/Safety Support– Additional time can be added each day when participants require more supervision/assistance that is not directed to individual tasks.
– Can also be justified for those with moderate or high fall/safety scores shown on the last page of the InterRAI
– This all MUST be heavily justified with certain conditions/diagnoses such as paralysis of any type (paraplegia, hemiplegia, quadriplegia) or Intellectual Development Disability such as Dementia, Alzheimer’s, etc. stated in the rationale beside the section.
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