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1300AGECARE

Who We Are
How We Help
Getting Started
Resources
Where to find us
Contact Us

Care, Health and Risk Review

Home Care, Health and Risk Review

Person Filling(Required)

First Last

Name of the Person filling out this form

Your Email(Required)

Enter Email Confirm Email

Participants Details

Participants Name(Required)

First Last

Date Of Birth(Required)

MM slash DD slash YYYY

Care Recipient ID(Required)

Franchise ID(Required)

Type of CHR review

New Participant

Annual

Change of need / unscheduled check in

Requested by participant or carer

Scheduled check in

Has consent been given by the participant to do this review?(Required)

Yes.

List all persons involved in the CHR review

What is the mode of this CHR review with the participant?

Face to face

Over the phone

Teleconference with video - Facetime, WhatsApp

Have all the previous CHR review actions been completed?

Yes

No

N/A first review

Please provide further details(Required)

Select which of the following documentation up to date. If any is not, then update.

Emergency response plan and emergency relocation plan

Home, environment and personal safety assessment

Personal information on Visual Care

Advance care plan

Risk and Vulnerability Status as per ACQSC criteria?

Has consent been given by the participant or their representative to share the information collected?(Required)

Yes.

Section 2

Health, risks and wellbeing screening questions

Change in health status

Unexplained weight loss (>5% in 1 month or >10% in 6 months)

Persistent or worsening pain affecting daily function

Increased fatigue, weakness or frailty

Sudden or gradual decline in mobility (e.g. requiring more assistance, increased falls)

Unusual swelling (legs, feet, hands)

Unplanned admission to hospital or respite

N/A - no changes observed or reported

Falls and mobility issues

New fall or recurrent falls (> 2 falls in 3 months)

Increase fear of falling, unsteady gait, or dizziness

Difficult transferring, standing or walking

Client has had a recent hospitalisation due to a fall

N/A or not observed or reported

Cognitive and behavioural changes

Increased confusion, forgetfulness or disorientation

Behavioural changes (e.g. agitation, aggression, withdrawal)

Wandering or safety concerns due to cognitive impairment

Family/ carer concerns about memory loss or decision making

Sudden or worsening depression, anxiety and social withdrawal

N/A - not observed or reported

Wound and skin integrity concerns

New or worsening wounds requiring clinical care

Signs of infection (redness, swelling, pus, odour, fever)

Skin breakdown or pressure sores

Unexplained bruising or fragile skin

Poor wound healing despite existing care interventions

N/A - not observed or reported

Medication issues

Client missing doses, forgetting or refusing medications

Medication side effects (e.g. dizziness, nausea, confusion, falls)

Incorrect medication administration reported by care staff or family

Newly prescribed high-risk medication requiring monitoring (e.g. anticoagulant, insulin, opioids, S8)

N/A - not observed or reported

Continence and hydration concerns

Sudden or worsening incontinence (bladder or bowel)

Persistent constipation or diarrhoea

Blood in urine or stool

Signs of dehydration (e.g. dry mouth, sunken eyes, confusion, skin turgidity test)

N/A - not observed or reported

Respiratory or cardiovascular symptoms

New or worsening shortness of breath (at rest or with minimal activity)

Irregular heartbeat, chest pain or dizziness

Persistent cough, wheezing, or difficulty breathing

Sudden swelling in the legs, ankles, or feet (potential heart failure)

N/A - not observed or reported

Palliative or end of life care needs

Client has life limiting condition requiring management

Pain, breathlessness, or other symptoms not well controlled

Family has requested additional palliative support

Client transitioning to end of life

Client expressing wishes to palliate or be support in comfort care / end of life at home

N/A - not observed or reported

Incident and risk management

Serious or recurring incidents (falls, medication errors, injuries)

Pattern of near misses suggesting increased risk

Family, staff or external providers raising safety concerns

Open disclosure required for a clinical incident

N/A- not observed or reported

Social and environmental risks

Concerns about neglect, self-care, or unsafe living conditions

Suspected abuse (physical, emotional, financial, sexual)

Family conflict impacting care decisions

Home environment not supporting current care needs (e.g. no appropriate equipment)

N/A - not observed or reported

Is there any other support requirement that is not listed or information that you would like to share?

List of validated assessments used

Bathel Index for activities of daily living

KICA, Rudas, Pas, SMMSE (mini mental)

FROP-COM -Falls Risks for older People in Community

Mini Nutritional Assessment (MNA)

Abbey Pain Scale

Geriatric Depression Scale (GDS)

Caregiver Strain index

Duke Social Support index

Good Spirit Good life Tool, Personal well-being index

Edmonton Frailty scale

Braden Risk Assessment, Norton, Waterlow

Kessler psychological distress scale (K10)

Oral Health assessment (OHAT)

De Morton Mobility scale (DEMMI)

Revised Urinary Incontinence, and Revised Faecal

Incontinence scales (RUIS & RUIS)

Please list results and outcomes of any assessments i.e. scale result, improvement, decline.

Have the following been updated where relevant?

Care / Support Plan

Service Agreement

Care and Services schedule - notification to schedulers

Notification to care and clinical team

Visual Care notes updated

Communicate with older person and or family

Communicate with care workers and others or /contractors

Completing incident report or notification

Have the relevant people informed of the changes?

Yes

No

Has the participant risk and vulnerability (OPRAV) screening been reviewed and if necessary updated?

Yes

No

N/A

Section 3

Date of this CHR review

MM slash DD slash YYYY

Next planned CHR review date

MM slash DD slash YYYY

Would you like to answer a few questions on how satisfied you are with the services we provide?

Yes

No

How would you rate your overall satisfaction with the care and customer service provided by Senior Helpers?

Very satisfied

Satisfied

Neutral

Unsatisfied

Very unsatisfied

How likely are you to recommend us to a friend or family member?

0

1

2

3

4

5

6

7

8

9

10

0 Not likely 10 Very Likely

Do you have any suggestions or comments that would help us improve our services?

Jessica Ponting

Operations Manager

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Christina Chartrand

Vice President of Training

Christina has over 25 years’ experience of training and teaching. She has created numerous training programs on a variety of topics for families, employees, managers and business owners, including the Senior Gems® and Parkinson’s Care Programs.

Robert Sharkey

Chief Financial Officer

Robert came to Senior Helpers in 2013 with an extensive background in finance and operations across many businesses, including Medicare.

Mari Baxter

Senior Vice President of Operations

Mari is responsible for managing the Business Development Team. She has been with Senior Helpers for over 10 years with 14 prior years’ experience as a successful business owner and entrepreneur.

Peter Ross

Chief Executive Officer & Co-Founder

Peter co-founded SH Franchising with Tony Bonacuse in 2004 and is the current CEO for Senior Helpers. He has led the organisation to become a national leader in non-medical home care in the USA. He is also the past President of the Home Care Association of America’s board of directors.

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163 Sheridan Street, Cairns North, QLD 4870

1300 AGECARE or 1300 243 2273

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07 4281 6816

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