long term care insurance claims onsite assessments read carefully before scheduling ... ·...

LONG TERM CARE INSURANCE CLAIMS ONSITE ASSESSMENTS READ CAREFULLY BEFORE SCHEDULING THE VISIT

• THIS VISIT MUST BE COMPLETED WITHIN 5 DAYS and FAXED BACK WITHIN 24 HOURS OF SCHEDULED DATE

• A CALL MUST BE MADE TO THE INSURED WITHIN 24 HOURS OF

RECEIPT OF THIS REFERRAL.

• See following pages for instructions and the script that must be followed for scheduling the assessment.

• ONCE THE VISIT IS SCHEDULED, COMPLETE THE BOTTOM HALF OF

THIS FORM AND FAX IT BACK TO LTS AT 508 907 6292, OR CALL THE SCHEDULING LINE, TOLL FREE 877 443 3777, EXT 124 or OPTION 3

INSURED NAME:_________________________________________ SCHEDULED DATE AND TIME:______________________________

Assessor Name and Phone:____________________________________

Insured Name: ________________________________________________________________

FIELD ASSESSOR:

You are required to show appropriate identification to the insured/representative prior to completing the onsite visit, along with a copy of the Referral letter from LTS.

The following are acceptable forms of identification:

• State issued ID • Driver’s license • Agency ID

Return this form with the assessment to LTS.

PLEASE HAVE THE INSURED/REPRESENTATIVE READ AND SIGN

By signing below, I confirm that the field assessor has shown an appropriate form of identification, along with the Referral letter from LTS, before completing the onsite assessment.

Insured/Representative Signature: __________________________________________________________

Insured/Representative Printed Name: _______________________________________________________

Date: ____________________________________________

*** THIS MUST BE READ AND SIGNED BELOW ***

Instructions for Completing the John Hancock Assessment

You MUST read and follow the instructions/script on pages A1, A2 and B1 carefully.

The scripts must be followed, all blank spaces must be filled in (including your credentials with signature), and

those pages must be returned with the rest of the assessment. Please PRINT all answers legibly in dark ink.

You must write in the time that the assessment begins on page B2, and the time the assessment ends on B16.

Please read each question carefully, and only answer the question that is being asked – do NOT write additional

comments. Page B3 – Question #6, if the insured has lost or gained weight, please circle the appropriate choice.

Page B4 – Medications - fill out all information in the grid (dose, route, freq, reason, etc), or indicate clearly the

reasons why the information could not be verified with prescription bottles. Page B4 – Review the medication list and be sure there is a corresponding diagnosis on page B3 for each

medication. You must read the instructions on the STOP page prior to completing the cognitive test (MMSE~2) and the

Behavior section. ** All responses to the cognitive test must be documented, verbatim ** You must read the instructions on the STOP page prior to completing the ADL section.

Read each of the ADL questions carefully and only answer the question being asked.

Do not collect additional information/documents from the insured /family to send to LTS with the assessment.

Please only return to LTS the completed assessment with no other pages attached (except for medication lists from a facility). Please direct insureds/families to send any additional documents directly to John Hancock.

I have read the instructions above. Assessor Signature: _________________________________________________________

ASSESSOR: PLEASE LEAVE THIS AT TIME OF ASSESSMENT FOR CLAIMANT/FAMILY

YOUR FEEDBACK IS VERY IMPORTANT TO US.

Long Term Solutions (LTS) is the company that John Hancock has chosen to provide the onsite assessment service as part of their long term care insurance claim process. As a trusted partner of John Hancock, LTS is committed to providing the highest quality service to John Hancock’s policyholders. In order to continue to meet, exceed and continuously improve upon our service, we are requesting your feedback regarding the onsite assessment you just completed.

Please call the toll free number listed below to complete a brief, customer satisfaction survey.

1-877-935-5040 I thank you for your input and time.

Sincerely,

Anne Harrington

Chief Operating Officer

Long Term Solutions

[ A1 ]

POLICY # CLAIM #

The contents of this form are considered proprietary and confidential and its use is restricted to John Hancock’s contracted vendors only.

LTC-1039Full 5/14

Step 1: Arrange the AppointmentINTRODUCTORY SCRIPTIt is important that you read the introductory script verbatim to the insured or responsible party when you call to introduce yourself and arrange an appointment for the on-site assessment.

Hello, my name is______________. I am a Registered Nurse contracted with (insert Vendor name here) and I am calling about your John Hancock Long-Term Care Insurance claim. I do not work for your long-term care insurer.

I am calling to schedule an appointment to complete an on-site assessment for John Hancock and would like to arrange to visit you/the insured, in the next few days.

If you would like a family member or other responsible party to be present during the assessment, please contact that person prior to the visit.

At the time of visit, please have the following information available: • Picture ID• List of ALL current OTC and prescribed medications you use/the insured uses and all related diagnoses.

Please have prescription bottles available for review

Step 2: Review the Face-to-Face GuidelinesPRIOR TO THE VISITPrior to conducting the on-site assessment, please read and review the instructions for the on-site and clinical guidelines below.

PURPOSE OF THE ON-SITE ASSESSMENTThe purpose of the assessment is to provide an objective picture of the insured’s current health status, cognitive, and functional abilities.

YOUR OBLIGATIONNote: Under your contract, you are obligated to provide the vendor with a complete assessment.

It is important to submit a complete assessment to assure prompt payment.

Please only complete the questions on this form. Do not include or attach additional information other than the medication sheet from physician or facility. See page B4.

It is also important for you to have proper identification on you at all times to verify that you:

• are a Registered Nurse able to perform the assessment

• have been contracted by ________________________

On-Site Assessment PRIOR TO THE ON-SITE ASSESSMENT

Long Term Solutions

[ A2 ]

POLICY # CLAIM #


LTC-1039Full 5/14

COMPONENTS OF A COMPLETE ASSESSMENTA complete assessment includes the following:• Your signature on the assessor confirmation below prior to completion of the interview.• A thorough, accurate, and complete depiction of the insured’s current health.• Answers to every question on the assessment. It is of great importance that all information on the assessment is

accurate, consistent, and legible.

Step 3: Complete Assessor Confirmation

READ, REVIEW, AND SIGN BEFORE YOUR INTERVIEW BEGINS

I acknowledge and agree that:(ASSESSOR’S NAME AND CREDENTIALS)

I. At no time during my visit with the insured willI represent myself as an agent of the insurancecompany; and

II. At no time during my visit with the insured will Ianswer any questions relating to the insured’s long-term care insurance coverage, policy, or benefiteligibility and if the insured asks any such questions, Iwill redirect the insured to the insurance company; and

III. I will observe the insured complete the demonstrationsdescribed in the Activities of Daily Living Section ofthe assessment tool when appropriate; and

IV. I will have reviewed all John Hancock trainingdocumentation provided by the vendor prior to myvisit with the insured; and

V. I will record all information regarding the insured,including any observations of demonstrationsrequested in this tool, and attest that all suchinformation and observations are truthful andaccurate to the best of my knowledge; and

VI. I understand my role as an independent contractorand upon completion of the assessment all contactbetween myself (the assessor) and the insuredand/or his/her designee/representative/familymember/POA will be severed.

ASSESSOR’S SIGNATURE:

LICENSE NUMBER(S): DATE:

[ B1 ]

POLICY # CLAIM #


LTC-1039Full 5/14

Step 1: Insured Disclaimer Statement

READ TO THE INSURED BEFORE YOU BEGIN THE ON-SITE ASSESSMENT

Thank you for meeting with me. My name is ______________________________ and I am a Registered Nurse from ______________________________. I am here to assess you in response to your claim for Long-Term Care Benefits with John Hancock.

Once the assessment is completed, I will have no further involvement with your long-term care insurance claim, and any questions regarding the claim process or this assessment should be directed to John Hancock at 1-800-233-1449.

I will be asking some questions that focus on your functional and cognitive abilities and will be collecting a list of your medications. In addition, I will ask you to demonstrate some activities of daily living. At times I will need to stop and write things down to ensure accurate information. All information will remain confidential. Thank you in advance for your patience.

My visit with you does not mean that John Hancock has agreed to pay your benefits. I do not determine eligibility for benefits, nor do I have any information about your insurance policy. The Long-Term Care Claim Department at John Hancock will notify you about your benefits after reviewing the information. You may be contacted by John Hancock for any additional documentation that they may need.

This assessment will take approximately 60-90 minutes. If at any time you need a restroom break, to take medications, or need food or a beverage, please feel free to interrupt me. I will be flexible and accommodate any needs you may have so that you are comfortable during my visit.

ON-SITE ASSESSMENT VISIT

Long Term Solutions

[ B2 ]

POLICY # CLAIM #


LTC-1039Full 5/14

Step 2: Baseline Information

INSTRUCTIONSObtain answers to the questions either by talking with the insured; or if the insured has a severe vision, hearing, or speech problem that makes communication unreliable or impossible, then speak with the insured’s responsible party, a caregiver, or facility staff.

BEGIN TIME: AM/PM

1. Insured Name: first last

2. Insured’s Date of Birth: (MM/DD/YY)

3. Form of Identification: n Drivers License n Social Security Card n Passport n Facility ID Bracelet n Other:

4. In what type of residence do you live? n Private Home/Apartment n Assisted Living Facility n Nursing Home n Independent Living Facility n Locked Memory Care Unit n Other (Please Specify):

5. With whom do you live? n Alone n Spouse/Partner n Family Member n Friend n Other (Please Specify):

6. Years of school completed:

THIS SPACE FOR INTERNAL USE ONLY.

[ B3 ]

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LTC-1039Full 5/14

Step 3: General Questions

INSTRUCTIONSEnsure all questions are answered thoroughly and handwriting is neat and legible. It is of great importance that all information on the assessment is accurate, consistent and legible.

1. Do you have any vision problems? n No n Yes If Yes, please describe:

2. Do you have any hearing problems? n No n Yes If Yes, please describe:

3. Do you have any speech problems? n No n Yes If Yes, please describe:

4. How tall are you? ft. in. n Measured n Reported

5. How much do you weigh? lbs. n Measured n Reported

6. Have you lost/gained more than 10 pounds, without trying, over the last six months? n No n Yes

7. Please provide your primary physician’s name, telephone number, and date last seen:

Doctor:

Phone: Date:

8. Have you had a neurological examination/assessment? n No n Yes

9. If yes, please indicate the physician’s name, telephone number, and date of the exam:

Doctor:

Phone: Date:

10. What are your current health conditions/diagnosis?

CONDITION/DIAGNOSES ESTIMATED ONSET DATE CONDITION/DIAGNOSES ESTIMATED ONSET DATE

[ B4 ]

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LTC-1039Full 5/14

Step 4: Medication Management

INSTRUCTIONSObtain information about all medications and treatments (e.g. TPN, oxygen) currently used by the insured. Ask the insured to show you all of his/her prescription bottles and containers, as well as the over-the-counter medications, vitamins, and supplements that are currently used.

If you are able to get a copy of the insured’s medication sheet from the facility, you do not need to write the insured’s medication in the grid below. Attach the medication sheet(s) to the assessment. Note: If attaching the medication sheet from the facility, the Medication Management question below still must be completed.

n DOES NOT CURRENTLY TAKE MEDICATION.

MEDICATION DOSE ROUTE FREQUENCY REASONPRESCRIBED BY OR N/A

(OTC)

VERIFIED BY PRESCRIPTION BOTTLE

YES NO

n n

n n

n n

n n

n n

n n

n n

n n

n n

n n

n n

n n

If not able to verify prescription by bottle, please indicate why:

MEDICATION MANAGEMENT (PLEASE CHECK ONE):

n Completes independently

n Completes with verbal prompts

n Completes with visual aides (e.g. med list, pill box, medication cassette)

n Unable to complete unless administered by someone else

n Able to complete independently, but has the facility administer medication(s)

[ B5 ]

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LTC-1039Full 5/14

Read BEFORE Proceeding to the Folstein MMSE-2, 2010

1. Before you administer the questionnaire, have the insured to sit down and face you.

2. If the insured uses hearing or visual aids, instruct the insured to utilize them before starting.

3. The MMSE-2 should be administered in less than 10 minutes — do not allow the insured to struggle at length to answer questions.

4. If family or others are present, explain that it is important that they do not answer for or prompt the insured.

5. If the insured answers incorrectly, the score is 0. Do not prompt or give physical clues such as head shaking.

6. Do not tell the insured when he/she makes a mistake. Everything the insured says is acceptable.

7. If the insured interrupts e.g. “What is this for?” reply “I will explain in a few minutes when we are finished. Now if we could just proceed….we are almost finished….”

8. Ask each question a maximum of three times. If the insured does not respond, the score is 0.

9. Administer the Folstein MMSE-2.

10. Check all of the below that are present:

n Vision deficit

n Unable to speak

n Dexterity (hand) impairment

n Hearing deficit

n Hand tremors

n Does not read or write

n Language barrier

n Refused to participate

JUDGMENTAfter completing the MMSE-2, please have the insured answer the following questions:

1. At night, if you need some help, how would you get it?

2. If you see smoke in a wastepaper basket and had no limitations, what action would you take?

Step 5: Cognitive Assessment Visit

MMSE~2 • You MUST read each question exactly as it is written

and write the insured’s responses verbatim

• Do not leave any blanks

• On the second page in the NAMING section, you must point to an EYE and EAR, not other items

• In the COMPREHENSION section, you must ask the insured to POINT to the ‘circle’, then POINT to the ‘square’, and then POINT to the ‘triangle’. (Do NOT ask the insured to draw the shapes or to name them) In the scoring section, record the response by: o Drawing the shapes in the order that the policy

holder pointed to them OR

o Marking a check mark for each correct response • One point should be given for each shape the insured

identified in the correct order • If this is not filled out correctly, the assessment will be

returned to you for corrections

[ B6 ]

POLICY # CLAIM #


LTC-1039Full 5/14

BEHAVIORAL GRIDObtain the following information from the insured (if he/she is able to provide) and/or an individual familiar with the insured’s behavior and fill in the Behaviorial Grid below, completing each row. Each Behavioral Symptom includes examples of the behaviors you should document.

Reported Behaviors

Please record any reported behaviors in the grid below.

BEHAVIORAL SYMPTOMS YES NOFREQUENCY

(DAILY, WEEKLY, OR MONTHLY)

DOCUMENT THE INSURED’S EXPERIENCE/EXAMPLES

AGITATION/AGGRESSION/ABUSIVE/ASSAULTIVE:e.g., Verbal threats, throws things, pushes, slaps and/or hits others

n n

DELUSIONS: (FALSE BELIEFS)e.g., Falsely believes house is being invaded, or family members are imposters or spouse is being unfaithful

n n

DISINHIBITION:e.g. Excessively familiar with strangers, inappropriate touching of others, taking off clothes in public

n n

BIZARRE HYGIENE:e.g., Wearing urine- or stool-soiled clothes, hoarding and/or hiding soiled item, placing clean incontinence pads on top of soiled incontinence pads

n n

BIZARRE EATING:e.g., Eating nonfood items n n

HALLUCINATIONS:e.g., Hears voices, sees, smells, and/or feels things which are not there

n n

PERSEVERATION:e.g., Same question, word, activity, or action repeatedly

n n

WANDERING:e.g., Continuous movement from place to place, pacing, elopement attempts, entering unauthorized or private spaces, gets lost in familiar surroundings

n n

RESISTIVE TO AND/OR REFUSES CARE:e.g., refers to any behavior which prevents or interferes with the care provider performing or assisting with any of the following ADLs for the person. ADLs: Bathing, Dressing, Eating, Transferring, Toileting, Continence Management, Ambulating

n n

[ B7 ]

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LTC-1039Full 5/14

Observed Behaviors

Please record any observed behaviors in the grid below.

BEHAVIORAL SYMPTOMS DOCUMENT OBSERVED BEHAVIOR DURING THE ASSESSMENT

AGITATION/AGGRESSION/ABUSIVE/ASSAULTIVE:e.g., Verbal threats, throws things, pushes, slaps and/or hits others

DELUSIONS: (FALSE BELIEFS)e.g., Falsely believes house is being invaded, or family members are imposters or spouse is being unfaithful

DISINHIBITION:e.g. Excessively familiar with strangers, inappropriate touching of others, taking off clothes in public

BIZARRE HYGIENE:e.g., Wearing urine- or stool-soiled clothes, hoarding and/or hiding soiled item, placing clean incontinence pads on top of soiled incontinence pads

BIZARRE EATING:e.g., Eating nonfood items

HALLUCINATIONS:e.g., Hears voices, sees, smells, and/or feels things which are not there

PERSEVERATION:e.g., Same question, word, activity, or action repeatedly

WANDERING:e.g., Continuous movement from place to place, pacing, elopement attempts, entering unauthorized or private spaces, gets lost in familiar surroundings

RESISTIVE TO AND/OR REFUSES CARE:e.g., refers to any behavior which prevents or interferes with the care provider performing or assisting with any of the following ADLs for the person. ADLs: Bathing, Dressing, Eating, Transferring, Toileting, Continence Management, Ambulating


Activities of Daily Living ** YOU MUST READ THESE INSTRUCTIONS **

• If assistance is needed with an ADL, document the reasons why in the

appropriate space BELOW the grid, under Need Assessor Response. Consider starting statement with “I observed…” (Do not write “Fall Risk” or “Needs help”. Please provide the reasons why, with as much detail as possible. IE: “I observed claimant cannot bend at waist”, “I observed claimant has poor balance”, “…limited ROM in shoulders”, etc)

• Every task in the grid must be addressed – something must be checked (either N/A, OR some level of assistance, OR the claimant did not demonstrate it).

• If assistance is needed for a task, be sure to check the frequency.

• ADL demonstration is a simulation only. Do NOT ask the insured to disrobe to demonstrate dressing, bathing or using the toilet. MIMIC only.

• For each ADL, you must answer whether the insured needs cueing

due to cognitive impairment.

• Do NOT write additional comments anywhere on this assessment. Simply read each question carefully and answer the question being asked.

[ B8 ]

POLICY # CLAIM #


LTC-1039Full 5/14

Step 6: Activities of Daily Living

CONTINENCEAre you ever incontinent or do you use a catheter or ostomy bag? If No, please proceed to the next page. n No n Yes

How often do you experience loss of bowel or bladder control that needs you to change your adult protective garment and/or your clothes? n Never n Always n Sometimes, please specify how often:

If the insured answered always or sometimes, please ask the insured if he/she needs human assistance with any of the tasks below and how often human assistance is needed.

TASKS

REPORTED LEVEL OF HUMAN ASSISTANCE

REPORTED FREQUENCY OF HUMAN ASSISTANCE

N/A INDEPENDENT VERBAL CUEING

STAND-BY WITHIN ARM’S

LENGTHHANDS-ON DAILY

AT LEAST ONCE PER

WEEK

LESS OFTEN THAN ONCE PER WEEK

Performing personal hygiene when loss of bladder control occurs n n n n n n n n

Performing personal hygiene when loss of bowel control occurs n n n n n n n n

Getting assistance with catheter n n n n n n n n

Getting assistance with ostomy n n n n n n n n

Placing of soiled adult protective undergarment or clothing in an indoor waste receptacle

n n n n n n n n

Need Insured Response:Approximate date when human assistance began: (MM/YY)

Who provided responses to the questions above (check all that apply)? n Insured n Insured’s caregiver n Insured’s relative or other (specify):

Need Assessor Response:If human assistance is needed, please indicate why:

Does the insured need cueing in order to perform the Activity of Daily Living due to a cognitive impairment? n No n Yes


[ B9 ]

POLICY # CLAIM #


LTC-1039Full 5/14

EATINGEating does NOT refer to food preparation, cutting food, pouring liquids, or notification that the meal is ready.

Do you use any of the following adaptive utensils when you eat? (check all that apply):n No n Plate guard n Special utensils n Feeding pump

n Other (specify):

Please ask the insured if he/she needs human assistance with any of the tasks in the following chart and how often human assistance is needed.

TASKS





LENGTHHANDS-ON EVERY TIME

AT LEAST HALF THE

TIME

LESS OFTEN THAN HALF THE TIME

Bringing food into mouth n n n n n n n n

Chewing/swallowing (e.g. aspiration, choking) n n n n n n n n

Getting assistance with feeding tube/intravenous feeding n n n n n n n n






[ B10 ]

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LTC-1039Full 5/14

MOBILITY/AMBULATION Do you use any of the following adaptive equipment when you move from one place to another indoors? (check all that apply):n No

n Walker

n Rollator

n Wheelchair

n Furniture

n Stair Lift

n Cane

n Other (specify):

DemonstrationWhile utilizing any adaptive equipment/devices noted above, have the insured demonstrate how he/she would perform the act of ambulating to where he/she usually sleeps.

If it is unsafe for the insured to demonstrate this task, do not request a demonstration but rather be sure to document in detail why the task was not demonstrated.

Indoor Mobility/Ambulation

If human assistance is needed, please indicate the frequency of human assistance.

TASKS

OBSERVED LEVEL OF HUMAN ASSISTANCE





AT LEAST HALF THE

TIME


Ambulating from one room to another n n n n n n n n






[ B11 ]

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LTC-1039Full 5/14

MOBILITY/AMBULATION,CONTINUED:

Outdoor Mobility/Ambulation


TASKS






AT LEAST HALF THE

TIME


Includes negotiating curbs, ramps, sidewalks, and other uneven surfaces n n n n n n n n






[ B12 ]

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LTC-1039Full 5/14

TRANSFERRING Do you use any of the following adaptive equipment when you transfer? (check all that apply): n No

n Walker

n Hoyer or Mechanical Lift

n Lift chair

n Wheelchair

n Cane

n Other (specify):

DemonstrationWhile utilizing any adaptive equipment/devices noted above, have the insured demonstrate how he/she would perform the act of transferring by performing the tasks below.



TASKSINDEPEN-

DENT



VERBAL CUEING


LENGTHHANDS-ON DID NOT

DEMONSTRATEEVERY TIME

AT LEAST HALF THE TIME


Sitting to stand n n n n n n n n

Controlling descent to a seated position n n n n n n n n

IF INDEPENDENT WITH THE ABOVE, PLEASE HAVE INSURED PROCEED WITH THE FOLLOWING:

Moving from chair/wheelchair back to bed to a reclining position n n n n n n n n

Sitting up from a reclining position n n n n n n n n





[ B13 ]

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LTC-1039Full 5/14

DRESSING Do you use any of the following equipment/devices? (check all that apply): n Non Shoehornn Grabbern Walker

n Wheelchairn Velcron Splintn Cane

n Brace for leg n Brace for armn Artificial limb

n Other:

DemonstrationWhile utilizing any adaptive equipment/devices noted above, have the insured demonstrate how he/she would perform the act of dressing without disrobing



TASKS





LENGTHHANDS-ON

DID NOT DEMON-STRATE

EVERY TIME



Putting on and taking off any necessary braces, fasteners, or artificial limbs

n n n n n n n n n

Getting clothes from closet/dresser n n n n n n n n n

Fastening snaps, buttons, zippers, ties, or hooks n n n n n n n n n

Demonstrating act of putting on sweater or shirt n n n n n n n n n

Demonstrating act of putting on pair of pants n n n n n n n n n

Putting on usual footwear n n n n n n n n n

Putting on compression stockings n n n n n n n n n

Taking off compression stockings n n n n n n n n n





[ B14 ]

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LTC-1039Full 5/14

TOILETING Do you use any of the following equipment/devices when you toilet? (check all that apply): n No

n Raised seat

n Grab bars

n Commode

n Adult protective garments

n Bedpan

n Urinal

n Other:

DemonstrationHave the insured walk with you to where they toilet. Without disrobing and while using any of the adaptive equipment noted above, have insured demonstrate how he/she would perform the act of toileting.



TASKS





LENGTHHANDS-ON

DID NOT DEMON-STRATE

EVERY TIME



Getting to/from the toilet n n n n n n n n n

Getting on and off the toilet n n n n n n n n n

Demonstrating act of adjusting clothing and/or incontinence pads before/after toilet, commode, urinal, or bedpan

n n n n n n n n n

Demonstrating act of managing bowel/bladder hygiene n n n n n n n n n

Demonstrating act of emptying commode, urinal, or bedpan n n n n n n n n n

If the insured uses a commode/urinal/bedpan during a 24-hour period, indicate how often:





[ B15 ]

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LTC-1039Full 5/14

BATHING Bathing excludes washing face, hands, or back, or shampooing hair.

Where do you bathe most of the time? (Most refers to at least every other time) Please check one of the below: n Tub n Shower n Sponge bathing

Do you use any of the following equipment/devices when you bathe? (check all that apply): n No

n Grab bars

n Long-handled brush

n Hand-held shower

n Walk-in shower

n Bath/shower chair

n Other:

DemonstrationHave the insured walk with you to his/her bathing area. Once in bathing area and while utilizing any adaptive equipment/devices above, ask the insured to demonstrate how he/she (without disrobing) would usually wash upper and lower body, and dry upper and lower body. Have insured demonstrate how he/she would get in and out of shower/tub or perform a sponge bath.



TASKS





LENGTHHANDS-ON DID NOT

DEMONSTRATEEVERY TIME



Obtaining supplies for sponge bath n n n n n n n n n

Turning on/off water n n n n n n n n n

Controlling water temperature n n n n n n n n n

Disposing of water for sponge bath n n n n n n n n n

Getting into and out of tub or shower n n n n n n n n n

Demonstrating act of washing upper body n n n n n n n n n

Demonstrating act of washing lower body n n n n n n n n n

Demonstrating act of washing feet n n n n n n n n n

Towel dry n n n n n n n n n

[ B16 ]

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LTC-1039Full 5/14

BATHING, CONTINUED:




Does the insured need cueing in order to perform the Activity of Daily Living due to a cognitive impairment? n 3o n Yes

END TIME: AM/PM

ASSESSOR CERTIFICATION I certify that:

• the onsite is complete;• I have observed the insured complete the demonstrations described in the Activities of Daily Living section,

when appropriate; and• all comments are objective.

ASSESSOR’S SIGNATURE: DATE:

IF THE INSURED HAS ANY QUESTIONS, PLEASE DIRECT HIM/HER TO CALL JOHN HANCOCK AT 1-800-233-1449.


Information on this form is being provided as a courtesy and does not imply benefit eligibility. For questions regarding benefit eligibility, please contact your long term care insurance company. Long Term Solutions does not recommend the services of one provider over another.

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* Long Term Solutions’ Select Provider Network is a collection of service providers that have been directly evaluated by Long Term Solutions for high quality standards. The Select Provider Network was created by Long Term Solutions and is not affiliated with any insurance company. There is no obligation to use any provider listed as a “Select Provider”. A provider’s listing as a “Select Provider” has no bearing on whether or not an insurance company will approve a claimant’s use of the provider for care services.

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http://www.mypersys.com/

http://www.myhomepay.com/longtermsolutions

http://www.myhomepay.com/longtermsolutions

mailto:[email protected]

http://www.eldercare.gov/

http://www.carex.com/LTS

ASSESSOR: PLEASE GO THROUGH THIS CHECKLIST AFTER COMPLETING THE

ASSESSMENT AND RETURN IT TO LTS Insured’s name: __________________________________

Did you answer all of the questions in the assessment?

Did you describe the insured’s ability/inability to perform each ADL and make comments where appropriate?

Did you complete the cognitive testing, write in all responses, and score the test appropriately?

Did you sign and date the assessment?

If you used a separate piece of paper (or the back of a page) please remember to include it when faxing the assessment back to LTS

Please provide LTS with a phone number/email address where you can be reached in the event that an LTS staff member has a question for you

Please Print Name: ________________________________________________ Email Address: ____________________________________________________ Cell # ____________________________________________________________ Home # __________________________________________________________

Please visit the Field Assessor Center for Education (FACE) on our website for training information and helpful tips on

completing assessments for LTS

www.longtermsol.com

http://www.longtermsol.com/

long term care insurance claims onsite assessments read carefully before scheduling ... ·...

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