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* Date (MM/DD/YYYY):510 E 12th Street, Ste. 2Des Moines, IA 50319515.725.3333 800.532.3213www.iowaaging.govCase Management Assessment FormPrior to completing this form, please ensure the Aging & Disability Network Consumer Intake Form is complete and current. All fields onthis form marked with an asterisk (*) are required fields; the form will not be considered complete unless all required fields are marked.SECTION 1: GENERAL INFORMATION* Consumer name (as it appears on the Aging & Disability Network Consumer Intake Form):FIRST NAME* Type of assessment:MIINITIAL ASSESSMENTLAST NAMEREASSESSMENT* Name of person completing this assessment:FIRST NAMELAST NAMEAGENCY/ORGANIZATIONPHONE NUMBERName and relationship to consumer of others present at this assessment:NAMERELATIONSHIP TO CONSUMERNAMERELATIONSHIP TO CONSUMERNAMERELATIONSHIP TO CONSUMERRelease of Information:YESNO* Date of consumer’s next assessment (MM/DD/YYYY):* Assessment referral source (select one):AREA AGENCY ON AGINGHOSPITALCOUNTY SOCIAL SERVICES WORKERHOSPITAL DISCHARGE PLANNERCHILDHOUSING MANAGERDEPARTMENT OF HUMAN SERVICESICF/IDD FACILITYFAMILY MEMBER (NOT PARENT OR CHILD)INTAKE SPECIALISTFRIENDINTERMEDIATE CARE FACILITY DISCHARGE PLANNERGERIATRIC CARE MANAGERLAW ENFORCEMENTGUARDIANLEAD AGENCYHEALTH PROFESSIONALLINKAGES PROGRAMHEALTH SERVICES DEPARTMENTPARENTHOME CARE PROVIDEROTHERHOME HEALTH AGENCYUNKNOWNInterpreter needed:YESNOUNKNOWNReason for interpreter:PRIMARY LANGUAGEPRIMARY LANGUAGE AT HOMESIGN LANGUAGEInterpreter’s 9-V1 07/01/2018Case Management Assessment Form 1 of 6

SECTION 2: LIVING ARRANGEMENT* Current living arrangement:* Consumer other livingarrangement:LIVES ALONEWITH SPOUSE/PARTNERWITH SPOUSE & CHILDWITH CHILD/CHILDRENWITH OTHERSINFORMATION UNAVAILABLEALONESPOUSENURSING FACILITYCHILDHOMELESSN/AFAMILY MEMBERASSISTED LIVINGOTHERFRIENDICF/IDD FACILITYROOMMATEMENTAL HEALTH FACILITY* Total number in household, including consumer:SECTION 3: DENTAL STATUS* Consumer has a dentist:YESNO* Last time consumer saw adentist:MORE THAN 1 YEAR AGOWITHIN THE PAST YEAR* If the consumer has not seena dentist, does he/she needassistance locating one?YESNO* Consumer has dentalinsurance:YESNOWITHIN THE PAST 6 MONTHSSECTION 4: POWER OF ATTORNEY (Data in this section not collected by the IDA)Consumer has a power ofattorney:YESNODON’T KNOWType of power of attorney:GENERALMEDICALGENERAL & MEDICALLIMITEDPower of attorney information:FIRST NAMELAST NAMEPHONE NUMBERPOWER OF ATTORNEY EFFECTIVE DATE (MM/DD/YYYY)SECTION 5: CONSUMER RESOURCESEmploymentConsumer currently employed:YESNOEmployment status:YES, FULL-TIMEVOLUNTEERYES, PART-TIMEDISABLEDYES, FULL-/PART-TIME NOT SPECIFIEDRETIREDSOMETIMESUNEMPLOYEDTEMPORARY JOBSDON’T KNOWSEEKING EMPLOYMENTNO RESPONSEPARTICIPATING IN PRE-EMPLOYMENT ACTIVITIES/SUPPORTSN/A19-V1 07/01/2018Case Management Assessment Form 2 of 6

Employment (cont.)Consumer’s desired employment status:FULL-TIMEINTERESTED IN WORKING, BUT NEEDS EMPLOYMENT SUPPORTSPART-TIMENOT INTERESTEDTEMPORARY JOBSN/A DUE TO CHILD’S AGEINTERESTED IN A NEW JOBFinancial Resources* Current payment source(s) for services:COMMUNITY OPTIONS/COMMUNITY INTEGRATION PROGRAMMEDICARE SAVINGS PROGRAMLONG-TERM CARE INSURANCEOTHER GOVERNMENT (e.g., CHAMPUS, VA, etc.)LOW-INCOME SUBSIDYPRIVATE INSURANCEMEDICAIDPRIVATE PAYMEDICALLY NEEDYQMB-LIMITED MEDICAIDMEDICARE ADVANTAGESELF-PAYMEDICARE PART ASLMB-LIMITED MEDICAIDMEDICARE PART BSSI-RELATED MEDICAIDMEDICARE PART DWORKER’S COMPENSATION* Income source(s):ANNUITIESSENIOR COMMUNITY SERVICE EMPLOYMENTDIVIDENDS/INTERESTSOCIAL SECURITY (SS)MILITARY RETIREMENTSOCIAL SECURITY DISABILITY INCOME (SSDI)OTHER NON-WORK INCOMESUPPLEMENTAL SOCIAL SECURITY (SSI)PENSION/RETIREMENT BENEFITSUNEMPLOYMENT BENEFITSPUBLIC ASSISTANCE/CASH ASSISTANCEVETERANS BENEFITSPUBLIC ASSISTANCE-TANFWORK INCOMERAILROAD RETIREMENT BENEFITS (RRB)WORKER’S COMPENSATIONSelf-declared assets and resources:CONSUMER HAS STOCK/BONDS/CDS?YESMONTHLY INCOME FROM STOCK/BONDS/CDSNOCONSUMER HAS INSURANCE SETTLEMENTS?YESNOCONSUMER HAS SAVINGS ACCOUNTS?YESNONOCONSUMER HAS IRA/PENSION ACCOUNTS?YESNOCONSUMER HAS VETERANS BENEFITS?YESNONOCONSUMER RECEIVES MONTHLY INCOME FROM FARM RENTAL?YESNOCONSUMER HAS ANNUITY INCOME?YES19-V1 07/01/2018 TOTAL BALANCE OF CHECKING ACCOUNTS MONTHLY INCOME FROM IRA/PENSION ACCOUNTS MONTHLY INCOME FROM VETERANS BENEFITSCONSUMER HAS SOCIAL SECURITY/SSDI/SSI BENEFITS?YESMONTHLY INCOME FROM INSURANCE SETTLEMENTSTOTAL BALANCE OF SAVINGS ACCOUNTSCONSUMER HAS CHECKING ACCOUNTS?YES MONTHLY INCOME FROM SOCIAL SECURITY/SSDI/SSI BENEFITS FARM PROPERTY VALUEMONTHLY FARM RENTAL INCOME MONTHLY INCOME FROM ANNUITIESNO Case Management Assessment Form 3 of 6

SECTION 6: PHYSICIANS/HOSPITALIZATIONS (Data in this section not collected by the IDA unless in aggregate form)PhysiciansConsumer has a primary care physician:YESNOPrimary care physician information:FIRST NAMELAST NAMESPECIALTYADDRESSCITY, STATE ZIPPHONE NUMBEREMAIL ADDRESSReason for last visit to primary care physician:Primary care physician follow-up date (MM/DD/YYYY):Consumer has seen other physicians/specialists in the pastyear (outside of a hospital or nursing facility setting):YESNOSpecialist/other physician information:FIRST NAMELAST NAMEPHONE NUMBERDATE OF LAST VISIT (MM/DD/YYYY)Reason for last visit to specialist/other physician:HospitalizationsConsumer’s primary hospital:Phone number:Time elapsed since consumer was last discharged from an in-patient setting:CURRENTLY IN HOSPITALMORE THAN 30 DAYS1-7 DAYS (WITHIN THE PAST WEEK)MORE THAN 90 DAYS8-14 DAYSMORE THAN 180 DAYS15-30 DAYSNO HOSPITALIZATIONReason(s) for consumer’s hospitalization:CARDIAC ONCHEMOTHERAPYPSYCHOTIC EPISODEDEEP VEIN THROMBOSIS/PULMONARY EMBOLISMRESPIRATORY PROBLEMSGI BLEEDING OR OBSTRUCTIONSCHEDULED SURGICAL PROCEDUREHYPO/HYPERGLYCEMIA OR DIABETESUNCONTROLLED PAINIMPROPER MEDICATIONURINARY TRACT INFECTIONINJURY CAUSED BY FALL/ACCIDENTWOUND CAREIV CATHETER-RELATED INFECTIONOTHERMYOCARDIAL INFARCTION/STROKEMost recent discharge date (MM/DD/YYYY):19-V1 07/01/2018Case Management Assessment Form 4 of 6

Mental HealthAsk the consumer the following questions to screen for depression:1) ARE YOU BASICALLY SATISFIED WITH YOUR LIFE?YES 0NO 12) HAVE YOU DROPPED MANY OF YOUR ACTIVITIES AND INTERESTS?YES 1NO 03) DO YOU FEEL THAT YOUR LIFE IS EMPTY?YES 1NO 04) DO YOU OFTEN FEEL BORED?YES 1NO 05) ARE YOU IN GOOD SPIRITS MOST OF THE TIME?YES 0NO 16) ARE YOU AFRAID SOMETHING BAD IS GOING TO HAPPEN TO YOU?YES 1NO 07) DO YOU FEEL HAPPY MOST OF THE TIME?YES 0NO 18) DO YOU OFTEN FEEL HELPLESS?YES 1NO 09) DO YOU PREFER TO STAY AT HOME RATHER THAN GOING OUT ANDDOING NEW THINGS?YES 1NO 010) DO YOU FEEL YOU HAVE MORE PROBLEMS WITH MEMORY THANMOST?YES 1NO 011) DO YOU THINK IT IS WONDERFUL TO BE ALIVE NOW?YES 0NO 112) DO YOU FEEL PRETTY WORTHLESS THE WAY YOU ARE NOW?YES 1NO 013) DO YOU FEEL FULL OF ENERGY?YES 0NO 114) DO YOU FEEL THAT YOUR SITUATION IS HOPELESS?YES 1NO 015) DO YOU THINK MOST PEOPLE ARE BETTER OFF THAN YOU ARE?YES 1NO 0* Calculate the score (add total number of points from Yes/No columns above):0-5 NO OR FEW SYMPTOMS OF DEPRESSION6-10 MILD TO MODERATE SYMPTOMS OF DEPRESSION11-15 SEVERE DEPRESSION SYMPTOMSIf the consumer scores 6 or above, ask the following questions:1) OVER THE LAST TWO WEEKS, HAVE YOU HAD THOUGHTS THAT YOUWOULD BE BETTER OFF DEAD OR THAT YOU WANT TO HURT YOURSELFIN SOME WAY?YESNO2) DO YOU FEEL THESE THOUGHTS ARE A PROBLEM FOR YOU ORSOMETHING YOU MIGHT ACT ON?YESNOIf the consumer answers “yes” to either question, direct him/her to medical attention. If intent, plan and means are indicated,refer IMMEDIATELY and contact supervisor.Mood/Emotional FunctionHas the consumer been bothered by little interest or pleasure in doing things?YES, OFTENNO, NEVERYES, MOST OF THE TIMEUNABLE TO ASSESSYES, SOME OF THE TIMEDECLINED TO DISCLOSERARELY* Have the consumer’s mood indicators become worse as compared to his/her last assessment?YES19-V1 07/01/2018NOTHIS IS CONSUMER’S FIRST ASSESSMENTCase Management Assessment Form 5 of 6

SECTION 7: Services* Consumer is participating in the following service(s) or program(s):ADULT DAY CAREPERSONAL CAREASSISTED TRANSPORTATIONSELF-DIRECTED CARECASE MANAGEMENTTRAINING & EDUCATIONCHORETRANSPORTATIONCONGREGATE MEALSEAPA ASSESSMENT & INTERVENTIONCOUNSELINGEAPA CONSULTATIONEVIDENCE-BASED HEALTH ACTIVITIESEAPA TRAINING & EDUCATIONHEALTH PROMOTION & DISEASE PREVENTIONCG/GO COUNSELINGHOME-DELIVERED MEALSCG/GO HOME-DELIVERED MEALSHOMEMAKERCG/GO INFORMATION SERVICESINFORMATION & ASSISTANCECG/GO OPTIONS COUNSELINGLEGAL ASSISTANCECG/GO RESPITEMATERIAL AIDCG/GO SUPPLEMENTAL SERVICESNUTRITION COUNSELINGMENTAL HEALTH OUTREACHNUTRITION EDUCATIONHOME HEALTH AIDEOPTIONS COUNSELINGNURSINGOUTREACHOTHER* Are the services/programs meeting his/her needs?YESSOMETIMESNOUNCLEAR RESPONSE* Do any of the following help the consumer with his/her care?AAA PROVIDEDRESIDENTIAL HEALTH DENTVOLUNTEERPARENTOTHER RELATIVEPRIVATE PAID HELPSERVICE NEEDS* Which service(s) or program(s) does the consumer need:ADULT DAY CARESELF-DIRECTED CAREASSISTED TRANSPORTATIONTRAINING & EDUCATIONCASE MANAGEMENTTRANSPORTATIONCHORECG/GO ACCESS ASSISTANCECONGREGATE MEALSCG/GO COUNSELINGEVIDENCE-BASED HEALTH ACTIVITIESCG/GO HOME-DELIVERED MEALSHEALTH PROMOTION & DISEASE PREVENTIONCG/GO INFORMATION SERVICESHOME-DELIVERED MEALSCG/GO OPTIONS COUNSELINGHOMEMAKERCG/GO RESPITEINFORMATION & ASSISTANCECG/GO SELF-DIRECTED CARELEGAL ASSISTANCECDAC SERVICESNUTRITION COUNSELINGMENTAL HEALTH OUTREACHNUTRITION EDUCATIONHOME HEALTH AIDEOPTIONS COUNSELINGNURSINGOUTREACHOTHERPERSONAL CARENO SERVICES NEEDED AT THIS TIME19-V1 07/01/2018Case Management Assessment Form 6 of 6

Case Management Assessment Form. SECTION 1: GENERAL INFORMATION. Prior to completing this form, please ensure the Aging & Disability Network Consumer Intake Form is complete and current. All fields on . this form marked with an asterisk (*) are required fields; the form will not be considered complete unless all required fields are marked.