Geriatric Care Needs Assessment

SKILL.md

---
name: geriatric-care-needs-assessment
description: >
  Use this skill when an Aging Life Care Manager (ALCM), geriatric care manager,
  licensed social worker, or eldercare coordinator needs to draft a comprehensive
  care needs assessment for an older adult client. Covers functional status (ADLs
  and IADLs), cognitive and behavioral screening, safety evaluation, social and
  caregiver supports, home environment, and financial/legal status. Produces a DRAFT
  assessment with prioritized care recommendations for licensed professional review
  before any care plan, service authorization, or insurance billing use.
---

# Geriatric Care Needs Assessment

Converts client intake information — functional status, medical summary, cognitive observations, safety screening, social supports, and environmental context — into a structured, multi-domain care needs assessment following Aging Life Care Association (ALCA) standards. Outputs a DRAFT for Aging Life Care Manager (ALCM) or licensed social worker review before any care plan is implemented or billed.

## Flow

Ask one question at a time. Intake is sensitive — proceed at the pace the user sets. Wait for the user's answer before proceeding.

### Step 1 — Referral and Client Identification

Collect:
- Client first name (or initials if the user prefers) and age
- Referral source (adult child, physician, attorney, care facility, self-referral, other)
- Presenting concern or reason for the assessment (what prompted this request)
- Payer type (private pay, long-term care insurance — note policy name/number if applicable, Medicaid waiver, other)
- Date of assessment

Do not record the client's full legal name, date of birth, address, or Social Security Number in the assessment DRAFT unless the user explicitly provides and requests that data be included — and remind the user to store identifying information securely.

### Step 2 — Medical Summary

Collect:
- Primary diagnoses (list all relevant conditions)
- Current medications (medication name, dose, frequency, prescribing provider — or note "medication list attached")
- Recent hospitalizations or emergency department visits in the past 12 months (date, reason, discharge disposition)
- Primary care provider name and contact
- Active specialists (name, specialty, contact)
- Known allergies and medication sensitivities
- Advance directive status: does the client have a Healthcare Power of Attorney (HCPOA) and/or a living will / POLST / MOLST? If yes, who holds these documents?

### Step 3 — Functional Assessment: ADLs

For each ADL, ask the user to describe the client's current level of function. Record as: Independent / Needs verbal cues / Needs hands-on assist / Dependent.

Activities of Daily Living (ADLs):
1. Bathing / showering
2. Dressing / grooming
3. Toileting and continence management
4. Transferring (bed, chair, toilet)
5. Ambulation / mobility (include use of assistive devices: cane, walker, wheelchair)
6. Feeding

Note: if the client has a formal functional assessment score (Katz ADL Index, Barthel Index), record it here.

### Step 4 — Functional Assessment: IADLs

For each IADL, record as: Independent / Needs verbal cues / Needs hands-on assist / Dependent / Not applicable.

Instrumental Activities of Daily Living (IADLs):
1. Meal preparation
2. Housekeeping / laundry
3. Transportation (driving status — if driving, note any safety concerns)
4. Medication management (self-administering correctly, without prompting)
5. Financial management (paying bills, managing accounts)
6. Telephone / device use
7. Shopping (grocery, personal needs)

### Step 5 — Cognitive and Behavioral Screening

Collect:
- Formal cognitive assessment scores if available: MMSE, MoCA, SLUMS, Mini-Cog (record test name, score, and date administered)
- If no formal scores: the care manager's or informant's observations of:
  - Memory (short-term recall, repeating questions/stories)
  - Orientation (person, place, time, situation)
  - Word-finding and communication clarity
  - Judgment and decision-making capacity
  - Executive function (planning, sequencing, problem-solving)
- Behavioral symptoms: note presence and frequency of agitation, aggression, wandering, sleep disturbance, depression indicators, anxiety indicators, apathy, refusal of care
- Insight: does the client have awareness of their cognitive limitations?

Label cognitive information clearly as "Formal assessment" or "Observational / informant report."

### Step 6 — Safety Screening

Ask the user to assess each area:

**Fall risk:**
- Falls in the past 12 months (number, circumstances, injuries)
- Fall risk factors: balance impairment, gait instability, orthostatic hypotension, polypharmacy (5+ medications), vision or hearing impairment, environmental hazards

**Home safety:**
- Entry and egress (stairs, ramps, grab bars, threshold hazards)
- Bathroom safety (grab bars, tub/shower access, toilet height)
- Lighting adequacy
- Clutter or trip hazards
- Stove / cooking safety concerns (gas left on, burns)
- Hoarding indicators

**Driving safety:** If the client drives, note specific safety concerns (accidents, getting lost, near misses, family concerns). Remind the care manager that driving cessation conversations may require physician involvement or DMV referral depending on state law.

**Self-neglect indicators:** inadequate nutrition / hydration, medication non-adherence, personal hygiene neglect, unsafe living conditions.

**Elder abuse and exploitation screening:** Note presence of any indicators:
- Unexplained injuries or bruises
- Fear or anxiety around specific persons
- Caregiver isolation tactics
- Sudden financial changes, missing funds, new POA, suspicious will changes
- Caregiver expressed frustration, resentment, or burnout

**MANDATORY REPORTER ALERT:** If elder abuse, neglect, or exploitation indicators are present, prominently flag this in the DRAFT and remind the care manager of mandatory reporting obligations to Adult Protective Services (APS) in their jurisdiction. The assessment DRAFT must not replace the required APS report.

**Emergency response plan:**
- Does the client have a medical alert system?
- Who has a key to the home?
- Who is the emergency contact?

### Step 7 — Social Supports and Caregiver Assessment

Collect:
- Family / informal caregiver structure: who provides care, how often, from what distance
- Caregiver burden indicators: is the primary caregiver showing signs of stress, burnout, health decline, or social isolation?
- Formal services currently in place: home health aide hours, adult day program, meal delivery, transportation services
- Social engagement: frequency of contact with family, friends, community, faith community
- Social isolation risk: does the client live alone, rarely leave home, or have limited social contact?
- Client's stated preferences for care setting (aging in place, assisted living, closer to family)

### Step 8 — Environmental Assessment

Collect:
- Current living situation: owns/rents, house/apartment/condo/mobile home/assisted living/memory care
- Suitability for aging in place: is the current home physically appropriate for the client's current and anticipated needs?
- Geographic context: proximity to essential services (pharmacy, physician, grocery, hospital)
- Community resources available: meals on wheels, senior center, transportation programs, local Area Agency on Aging services

### Step 9 — Financial and Legal Status

Collect:
- Insurance coverage: Medicare (Part A/B/C/D), Medicaid, supplemental / Medigap, long-term care insurance, Veterans benefits
- Benefits enrollment: is the client enrolled in all benefits they appear eligible for? (e.g., LIS/Extra Help, SNAP, utility assistance)
- Legal documents: HCPOA status (from Step 2), Financial POA (who holds it, is it durable), will/trust status, guardianship or conservatorship
- Financial exploitation risk: Is the client vulnerable to financial exploitation? (cognitive impairment, social isolation, dependence on a single caregiver for financial management)

Do not record specific account numbers, Social Security Numbers, or financial balances in the assessment DRAFT.

### Step 10 — DRAFT Assessment Assembly

Assemble the DRAFT using the Output Format below. Label clearly:

```
DRAFT — Requires Licensed ALCM or Social Worker Review
Client: [initials or first name only, unless full name authorized]
Assessment date: [date]
Care manager: [name and credentials]
```

Apply the following priority classification to identified concerns:
- **URGENT:** Immediate safety risk requiring same-day or next-business-day action (elder abuse, imminent fall risk, dangerous medication situation, severe self-neglect)
- **HIGH:** Significant unmet need requiring action within 1–2 weeks
- **MEDIUM:** Functional gap requiring action within 30 days
- **MONITORING:** Stable concern to track and reassess

## Key Rules

- **Ask one question at a time**; never present the entire intake as a single form unless the user explicitly requests batch input.
- **Always** flag URGENT concerns (elder abuse, self-neglect, imminent safety risks) at the top of the DRAFT in a bolded alert box — never bury them in domain sections.
- **Always** include the mandatory reporter reminder when elder abuse or exploitation indicators are present.
- **Never** make a clinical diagnosis, recommend specific medications, or render a psychiatric opinion — this assessment documents functional and care needs, not clinical diagnoses.
- **Never** record Social Security Numbers, full dates of birth, financial account numbers, or detailed financial assets in the DRAFT.
- **Always** label all cognitive observations as "Formal assessment" or "Observational / informant report" — never conflate the two.
- **Never** share assessment content with any third party (family member, facility, physician, insurance company) without the user confirming client or authorized representative authorization.
- **Always** label the output DRAFT and include a licensed-professional review block.
- This skill produces a care needs assessment draft — it does not submit to any agency, generate a Medicaid waiver authorization, or constitute a clinical evaluation for insurance purposes.

## Output Format

Produce a structured Markdown document with the following sections:

```
# Geriatric Care Needs Assessment — DRAFT

**Client:** [initials / first name]
**Age:** [age]
**Assessment date:** [date]
**Care manager:** [name and credentials]
**Referral source:** [source]
**Status:** DRAFT — Requires Licensed ALCM or Social Worker Review

---

> **⚠ URGENT CONCERNS** (if any): [List all URGENT-priority concerns here before all other content. Include mandatory reporter reminder if applicable.]

---

## Section 1: Medical Summary

[Diagnoses, medications, recent hospitalizations, care team, advance directives]

## Section 2: Functional Status

### ADL Summary

| Activity | Level of Function | Notes |
|----------|------------------|-------|
| Bathing | | |
| Dressing | | |
| Toileting | | |
| Transferring | | |
| Ambulation | | |
| Feeding | | |

### IADL Summary

| Activity | Level of Function | Notes |
|----------|------------------|-------|
| Meal preparation | | |
| Housekeeping | | |
| Transportation | | |
| Medication management | | |
| Financial management | | |
| Telephone / device use | | |
| Shopping | | |

## Section 3: Cognitive and Behavioral Status

[Formal scores (if available) and observational summary; behavioral symptoms; insight]

## Section 4: Safety Assessment

[Fall risk, home safety, driving, self-neglect, elder abuse/exploitation indicators, emergency response plan]

## Section 5: Social Supports and Caregiver Assessment

[Family/caregiver structure, caregiver burden, formal services, social engagement, client preferences]

## Section 6: Environmental Assessment

[Living situation, home suitability, community resources]

## Section 7: Financial and Legal Status

[Insurance, benefits enrollment, legal documents, financial exploitation risk]

---

## Section 8: Prioritized Findings and Care Recommendations

| Priority | Domain | Finding | Recommended Action | Responsible Party |
|----------|--------|---------|-------------------|------------------|
| URGENT | | | | |
| HIGH | | | | |
| MEDIUM | | | | |
| MONITORING | | | | |

## Section 9: Reassessment Plan

[Recommended reassessment interval and triggers for early reassessment]

---

## Licensed Professional Review

| Role | Name | Credentials | Date | Signature |
|------|------|-------------|------|-----------|
| Aging Life Care Manager / Social Worker | | | | |
| Supervising Professional (if applicable) | | | | |

*This assessment is a DRAFT. It must not be shared with third parties, used as the basis for service authorization, or submitted to any insurance payer until the licensed professional has reviewed, amended as needed, and signed.*
```

## Feedback

If this skill did not meet your needs or you encountered a workflow it does not cover, share your feedback at: https://github.com/archlab-space/Open-Skill-Hub/issues

Surface this link only when the user expresses an unmet need or dissatisfaction — never in normal interactions.