Form#AIAAA_CAQ_E10, Caregiver Assessment Questionnaire

By Tyler Jenkins,2014-10-17 12:08
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Form#AIAAA_CAQ_E10, Caregiver Assessment Questionnaire

    Texas Department of Aging and Disability Services

    Access & Intake/Area Agencies on Aging

    Instructions for completing the

    Caregiver Assessment Questionnaire


    stSenate Bill (SB) 271, 81 Legislature, Regular Session, 2009, relating to informal caregiver support services, directs the Department of Aging and Disability Services (DADS) to:

    ; raise awareness of services available to caregivers;

    ; perform outreach functions to informal caregivers; and

    ; gather information about the needs of caregivers through:

    o collection of profile data on informal caregivers;

    o provision of caregiver referral to support services when appropriate; and

    o implementation of a standardized caregiver assessment tool to evaluate the needs

    of caregivers.

    SB 271 requires DADS to use the information collected to refer informal caregivers to available support services and to:

    ; evaluate the needs of assessed informal caregivers;

    ; measure the effectiveness of certain informal caregiver support interventions;

    ; improve existing programs;

    ; develop new services as necessary to sustain informal caregivers; and

    ; determine the effect of informal caregiving on employment and employers. SB 271 also requires DADS to coordinate with Area Agencies on Aging (AAA) to develop and implement a protocol to evaluate the needs of certain informal caregivers. The protocol must provide guidance on the type of caregivers who should receive an assessment and include the use of a standardized assessment tool.

    In collaboration with AAAs and Community Services and Program Operations Section of DADS, the Access and Intake/Area Agencies on Aging Section has developed the Caregiver Assessment Questionnaire (CAQ) which incorporates a caregiver profile being implemented by LTSS staff throughout Texas.

    Form#AIAAA_CAQ_E1.0 Page 1 of 6

    Edition Date: 10/4/10


    A. Types of Caregivers to be Assessed

    The CAQ must be completed for all caregivers receiving Care Coordination or Caregiver

    Support Coordination funded through Title III-E of the Older Americans Act (OAA). For

    example, Respite Vouchers or authorization of Adult Day Care occurs under Care

    Coordination or Caregiver Support Coordination so the completion of the Caregiver

    Assessment is required for caregivers receiving these services under Title III-E. B. Standardized Assessment Tool

    The CAQ is used to:

    ; collect various types of data designed to evaluate the needs of informal caregivers;

    ; collect data in a uniform manner from all AAAs; and

    ; provide consistent caregiver data to DADS for evaluation.

    The CAQ is designed to meet the requirements of SB 271. The information collected will be

    analyzed and will be included in DADS’ report to the governor and the Legislative Budget

    Board. DADS is required to submit this report in December of each even-numbered year,

    beginning December 1, 2012.

    Completing the Paper Form

    The CAQ is required to be completed at intake when Care Coordination or Caregiver Support Coordination is identified as a need for a caregiver requesting assistance. The CAQ must be completed for each unduplicated caregiver based on the state fiscal year. This form may be completed by AAA staff during a face-to-face interview or by telephone. The AAA staff must discuss the questions with the caregiver. The caregiver may not be requested to complete the form by themselves and return the form to the AAA.

    A. Question Sensitivity

    Staff may find it awkward to ask certain questions on the CAQ. While understandable, all

    questions must be asked and a response recorded for each. It is not acceptable to skip a

    question. If an individual seems resistant to answering any of the questions, do not insist on a

    response. Simply document the individual refused to answer and continue to the next


    B. Caregiver Employment

    Check boxes have been provided as a means to record the ways caregiving responsibilities

    have affected the caregiver’s employment. After asking the open-ended question, staff should

    listen to the caregiver’s comments and check all of the boxes that apply. Interviewers are not

    expected to read aloud each possible response to the employment question; however, the list

    can be used as a prompt if the responder is unsure how to answer. If the individual seems

    uncertain, read aloud the response category headings. For example, “has caregiving affected

    Form#AIAAA_CAQ_E1.0 Page 2 of 6

    Edition Date: 10/4/10

    your employment schedule, pay, leave, performance, or work relationships?If further

    clarification is necessary considering asking: “For example, have you had to take extra leave

    or change your work schedule to meet your caregiver responsibilities?”

    C. Caregiver Stress Interview

    In this section, check boxes have also been provided as a means to record the level of stress a

    caregiver may be feeling because of caregiving responsibilities. Engaging in a dialogue with

    the caregiver can be an effective way to determine the level of stress a caregiver is

    experiencing for a given area. Ask open-ended questions. Approaching this area in a

    conversational manner can alleviate discomfort in asking these questions for both the staff

    and the caregiver.

    It is important to keep in mind the most complete and accurate information gained while completing the CAQ will result in DADS’ best analysis on a statewide level for reporting to the governor and Legislative Budget Board. More importantly, the AAA staff discussion with the caregiver may identify the best ways to help serve the caregiver.

    Entering the CAQ Responses into SAMS

    Each AAA is required to enter the CAQ responses into SAMS using the assessment function. The assessment document in SAMS mirrors the questions and responses on the paper form. The AAA is not required to complete a paper form if the environment allows for direct entry of the responses into SAMS.

    Form#AIAAA_CAQ_E1.0 Page 3 of 6

    Edition Date: 10/4/10

    Caregiver Assessment


1. Caregiver’s first name: 5. Caregiver’s relationship to care recipient:

     Other Relative 2. Caregiver’s last name: Child

     Other Non-Relative Friend

     Sibling Grandchild 3. Care recipient’s first name: Son/Daughter-in-Law Grandparent

     Spouse Life Partner 4. Care recipient’s last name: Refused to Answer Neighbor

    6. Caregiver Demographics and Living Arrangement 7. Assessment Time Start:

    8. Assessment Time End: a. Marital Status: Married Not Married Refused

    b. Hispanic Origin: Yes No Refused

    c. Race: Asian Black Native Hawaiian 9. Total Time: d. Lives with care recipient: White Refused Other Pacific

     Yes No Refused

    Caregiver Needs

    10. Were you aware of the caregiver support resources prior to making this contact? Yes No 11. If YES, have you received caregiver support services in the past? Yes No 12. If NO, what prompted you to seek help now?

    13. Do you have concerns about receiving the caregiver support? (Check all that apply)

     Care recipient reluctant to accept outside help No one else can provide care as well as I do

     Do not trust service providers in the home Other

     14. If “Other” was indicated above, please describe:

    Caregiver Profile

    15. Are you paid to provide care for [care recipient’s name]? Yes No (If Yes, stop here)

     Yes No 16. Are you the only non-paid person providing care to [care recipient’s name]? Refused to Answer 17. How long have you provided care for [care recipient’s name]? year(s) month(s) 18. How often do you provide care to [care recipient’s name]?