VA Geriatrics and Extended Care (GEC) Referral
1. Source of Referral
2. Living Situation
This referral is being made from?
2.1 With whom does the patient live?
2.2 Where does the patient live?
1.1 Outpatient Clinic
2.2.1 Private home/Apartment
1.2 Hospital < 7 days
2.1.2 Spouse only
2.2.2 Board and Care/Assisted Living
1.3 Hospital > 6 days
2.1.3 Spouse with others
2.2.3 Nursing Home
1.4 VA Nursing Home
2.1.4 Child (not spouse)
1.5 Community Nursing Home
2.1.5 Others (not spouse or children)
1.6 VA Domiciliary
2.1.6 Group setting with non-relatives
2.2.6 Homeless shelter
2.1.7 Other (Specify)
2.2.7 Other (Specify)
1.8 Other (Specify)
3. Primary Caregiver Information
6. Instrumental Activities of Daily Living
In the last 7 days, has the patient expressed
Check no caregiver only if there is no one on whom the patient
difficulty with the following activities?
relies on for any type of support. Do not check if there is ANY
person who provides ANY type of support
Consider how difficult it is or would have been for the
patient to perform these IADL activities on his/her own in
3.2 Last name
3.3 First name
the last seven days. If you have not seen the patient
perform these tasks, you must use your judgment.
3.4 Street Address
6.1 Preparing Meals (planning, cooking, setting out food
and utensils) Answer YES if patient does NOT prepare
meals, even if s/he could.
6.1.1 Were meals prepared by others?
6.2 Housework (e.g., dishes, dusting, laundry)
3.8 Telephone number with area code
6.3 Shopping (selecting items, managing money)
6.4 Transportation (getting to places beyond walking
3.9 Caregiver's relationship to patient? (Check one)
Child or child-in-law
6.5 Using the phone (receiving or making calls - may
use assistive devices)
3.10 Support provided by informal caregiver (Check all that apply)
6.6 Managing medications (remembering to take meds,
refill meds, opening bottles, correct dosages, etc)
6.7 Managing own finances (maintaining a checkbook,
3.11 Caregiver lives with patient?
paying own routine bills, etc.)
3.12 Caregiver accessible to patient?
6.8 Do any of the answers above (6.1 - 6.7) indicate
Lives close enough to see pt. and provide care
recent (e.g., 2-3 mo) change in functioning?
7. Services in the Home
3.13 Caregiver willing/able to increase help?
Code NO if patient has been in hospital, nursing home
Ask caregiver if s/he is willing, use your own
or out of the home for the time period of the question.
judgment about his/her ability to increase help.
7.1 In the last 14 days, has the patient received
Code NO if the caregiver is unwilling or, if in your
assistance from a home health aide in the home?
judgment, is unable.
7.2 In the last 14 days, has the patient received
assistance from a social worker in the home?
(Check any language the patient speaks and understands)
7.3 In the last 30 days has the patient received help in
the home from an RN? OR is an RN scheduled or
authorized to make home visits in the next 30 days?
5. Homebound Status
5.1 Is the patient homebound (able to leave the
PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL
home only infrequently and for short periods of
SOCIAL SECURITY NO.
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