Targeted Case Management Contact Monitoring Form Page 5

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46. Who is the primary caregiver being relieved?____________________________________________________________
47. Is the frequency of respite care adequate?______________________________________________________________
48. In what ways could respite care be improved? ___________________________________________________________
Complete if Attendant Care Services are on the PCSP:
N/A
49. How many attendants come to your home to help you?____________________________________________________
50. Did you hire the attendants that come to your home?
Yes
No
If no, what agency sent the aides or companions that come to your home? ___________________________________
________________________________________________________________________________________________
51. Are you related to your attendants?
Yes
No
If yes, how are you related to them?
__________________________________________________
________________________________________________________________________________________________
52. How long have your attendants worked with you? ________________________________________________________
53. Does your paid caregiver live in the home with you? If yes, provide his/her name?_______________________________
54. Have you had a change in the attendants working for you in the last 6 months?
Yes
No
If yes, how many times and why?
________________________________________________________________________________________________
________________________________________________________________________________________________
55. How long do your attendants usually stay each visit?______________________________________________________
56. Is the amount of time good for you?
Yes
No
If no, is it
Too long
Not enough time
57. How do your attendants help you? (List tasks and be specific) _______________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
58. What are your attendants not doing that you would like them to do?
Please list and be specific.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
59. Do your attendants come the same time every day?
Yes
No
60. Does someone help you take a bath?
Yes
No
If yes, who__________________________________________
5
DMS-690 (1-1-16)

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