This checklist is intended to assist you in identifying if there is an immediate need for care. Review the checklist below and if you identify that any of these changes have occurred, you should arrange for a consultation with your Park Cities Healthcare RN Case Manager so we can assess your entire situation and advise you or your loved one about available options.

Changes in Personal Care and Mobility or Activities of Daily Living

1. Difficulty with bathing, improper grooming or lack of proper hygiene
2. Incontinence and improper or incomplete bathing/cleansing of self and home
3. Forgetting to eat, not eating nutritious meals, sudden weight loss or lack of hydration
4. Increasing unsteadiness and/or falling down, or trouble getting out of chair
5. Difficulty doing laundry, dishes, and doing grocery shopping

Changes in Healthcare Status

1. Mismanagement of medication, confusion about what to take and when, inability to administer injection and wrap bandages
2. Recently diagnosed with life altering or chronic illness
3. Recently discharged from hospital, or going home after surgery
4. Frequent hospitalizations or trips to the Emergency Room
5. Recent physical impairment, including stroke, loss of limbs or other major injury

Changes in Life Management

1. Trouble paying bills or handling correspondence, or changes in purchasing patterns
2. Impaired judgment/decision making; or becomes victims of scams or financial abuse
3. Unable to use the telephone or does not answer the phone, or respond to messages
4. Expressed needs for help at home, things becoming too much to handle
5. Leaving the stove or other appliances on, letting bathtubs or sinks overflow, creating a safety hazard

Changes in Attitude/ Behavior

1. Sadness, loneliness, isolation, or confusion
2. Appearance has changed/deteriorated
3. Sudden mood swings, anger, anxiety or depression
4. Getting lost easily or starting to wander
5. Difficulty understanding others/remembering names or situations and locations

Changes in Family Situation

1. Recently lost a spouse or primary support/caregiver
2. Caregiver works and cannot respond to the clients needs on a regular basis
3. Family is overwhelmed by clients circumstances
4. Family is in conflict over how best to meet clients personal needs
5. Caregiver or family is geographically distant or has recently moved farther away from the client