- ADLs are used as a measurement of a person’s functional status
- First proposed in 1950 by Sidney Katz, who developed the first evaluation tool called the Katz ADL scale.
- Other assessment methods include the Barthel ADL Index, as well as the Roper–Logan–Tierney model of nursing
- ADLs consist of Basic ADLs and Instrumental ADLs
- Basics ADLs are more essential for survival than IADLs.
- Instrumental ADLs (IADLs) are not necessary for fundamental functioning, but they let an individual live independently in a community.
In this first part, we will define the following concepts and provide an overview of why they are important in the field of senior and disabled care:
- Activities of Daily Living (ADLs)
- Instrumental Activities of Daily Living (IADLs)
- Checklists, Functional Assessments, and Roper, Laughlin, and Tierney
- ADLs as Triggers for Financial Aid
- Plans of Care
Activities of daily living (ADLs) are basic tasks that must be accomplished every day for an individual to thrive. Generally, ADLs can be broken down into the following categories:
- Personal hygiene
Bathing, grooming, oral, nail and hair care
- Continence management
A person’s mental and physical ability to properly use the bathroom
A person’s ability to select and wear the proper clothes for different occasions
Whether a person can feed themselves or needs assistance
The extent of a person’s ability to change from one position to the other and to walk independently
Understanding how each category affects a person’s ability to care for themselves can mean the difference between graceful and independent aging and needing daily assistance. Financially, it can also mean the ability of an elderly or disabled person to become eligible for state and Federally-funded government help, or to qualify for reimbursements from privately owned Long Term Care Insurance policies (LTC insurance).
Instrumental activities of daily living (IADLs) are somewhat more complex but nevertheless also reflect on a person’s ability to live independently and thrive. IADLs thus include securing assistance for:
- Companionship and mental support
This is a fundamental and much needed IADL for daily living. It reflects on the help that may be needed to keep a person in a positive frame of mind
- Transportation and shopping
How much a person can go around or procure their grocery and pharmacy needs without help
- Preparing meals
Planning and preparing the various aspects of meals, including shopping and storing groceries
- Managing a person’s household
Cleaning, tidying up, removing trash and clutter, and doing laundry and folding clothes
- Managing medications
How much help may be needed in getting prescriptions filled, keeping medications up to date and taking meds on time and in the right dosages
- Communicating with others
Managing the household’s phones and mail and generally making the home hospitable and welcoming for visitors
- Managing finances
How much assistance a person may need in managing bank balances and checkbooks and paying bills on time
People often begin asking for outside assistance when these tasks become difficult to manage independently. Even though there are distinctions between ADLS and IADLs, the term activities of daily living often refers to both.
Assessments are a critical part of elder care, for they are at the core of both Plans of Care and the financial help that a person may get from the different payers for long term care (e.g. Medicaid and other state programs, as well as LTC insurance).
Understanding ADLs and IADLs is a great first step toward defining and securing appropriate care support. Several checklists have been developed by various entities, but they all more or less include checking all the above listed ADLs and IADLs against columns that specify “No help needed”, “some help needed”, or “total help needed”.
Together with in-depth assessments, checklists thus form the basis for an elderly person’s Plan of Care, commonly developed by the elderly person’s or disabled person’s primary care physician.
Across the medical and non-medical community, the concept of rating an individual’s ability to perform activities of daily living independently is an important tool. There is not a single universal ADL evaluation form, although there are almost as many ADL assessment tools as reasons to assess.
Here is how the different stakeholders in elder and disabled care use assessments:
- Case managers (typically social workers or RNs)
They collect information on a person’s ability to perform ADLs, information that enables them to plan ahead for each person’s continuum of care
- Primary care physicians
They rely on these assessments to formulate the Plan of Care
- Home health agencies (skilled nursing)
They depend on the Physician’s Plan of Care, while home care agencies (non-medical) depend on the assessments to formulate the nurse’s Plan of Care, to select the appropriate staff and caregivers needed for each care recipient and to monitor the staff and caregivers’ daily progress/service notes
- Physical and occupational therapists
They work in accordance with the Plan of Care and track and record ADL progress related to a rehabilitation or convalescing goal
- LTC Insurance providers
They require the assessments and caregiver daily service notes to disburse and regulate policy reimbursements
- Government agencies
They rely on ADL evaluations to qualify an individual and initiate and pay for the services rendered and monitor their continued effectiveness
While the temptation to reduce ADLs into a simple checklist is widely favored, there is always a concern that if ADLs were used only as a checklist, the assessing nurse’s own biases and preconceptions would influence the results. For example, if a nurse does not see the need to discuss a certain ADL with the patient, she may assume that the patient feels the same way, when in reality the patient may have other needs that do not come to the surface.
Roper, Laughlin, and Tierney
Health practitioners Roper, Laughlin, and Tierney thus developed a functional assessment model that was widely adopted in the United Kingdom and elsewhere as a standard for measuring and monitoring care. They conceptualized a holistic approach to treating and assisting a person. The concept begins by breaking human functions into 12 activities of daily living:
- Maintaining a safe environment
- Eating and drinking
- Washing and dressing
- Controlling temperature
- Working and playing
- Expressing sexuality
- Death and dying
These activities are then rated on a scale that ranges from completely independent to completely dependent.
Furthermore, the model creators intended for the activities of daily living assessment to be used in conjunction with 5 additional determining factors:
Biological factors take into account a patient’s current and past health history, strengths, and vulnerabilities
Psychological considerations address an individual’s core beliefs and cognitive functions, and how these may affect the individual’s ability to execute ADLs independently
Sociocultural factors consider the way a person’s history and cultural beliefs, and the beliefs of those around them, affect healing and the ability to function independently
Environmental factors consider how a person’s environment impacts healing and wellness
Financial considerations include aspects of how access to personal funds, and access to public and private programs and insurances work to accomplish health and wellness goals
An activities of daily living assessment (or a “geriatric assessment”) that combines the 12 activities of daily living with the 5 determining factors creates an assessment tool that thus becomes the bedrock of care strategy for a patient.
Finally, an activity of daily living assessment form is a tool that can help empower individuals when discussing care goals with medical professionals and care providers.
Most of us are already aware of the fact that Medicare does not fund long term care whether at home or in facilities. We thus examine in this section the most common payment triggers of Long Term Care Insurance (LTC insurance) policies, as well as Medicaid and other state-funded financial programs.
Benefit triggers are what insurers use to determine whether you are eligible for monetary amounts pursuant to the terms of the policy. Most insurers use a specific assessment form, typically filled out by the assessing nurse or another member of the medical team such as the case manager or social worker. Actual reimbursement payments commence when the bona fide medical assessment shows that the insured person is either cognitively impaired or needs assistance with at least two activities of daily living. Upon submitting the assessment, the insurer’s case manager will then typically approve the nurse’s Care Plan under which continued payments can be made.
The elimination period is similar to a deductible that must first be met before the insured patient can actually start receiving payments, and it is commonly set at the time of procuring the policy, not in terms of a dollar amount, but in terms of a period of time, such as for example 60 or 90 days. These periods of time, in which the patient must usually show that they are paying for care services from other means, are commonly intended to first allow the patient to reap Medicare Parts A and B benefits prior to insurance benefits. Once the elimination period expires, payments are made pursuant to the other policy benefits.
State-funded financial aid programs
Medicaid is a joint venture between the Federal government and each state whereby the local government provides subsidies and sets up guidelines for eligibility and governs the programs. Medicaid is intended as a safety net program for the poor and low income groups. It has asset, income, and needs test that determine a person’s eligibility.
Asset and income tests
The 2016 Medicaid asset and income tests would have you apply for free or subsidized care on any day of the year if you have a low net worth (less than $3,000 in many states), or if your individual annual income is $16,243 or less (or $33,465 or less for a family of four), i.e. 138% of the current Federal poverty line.
The Medicaid needs test is in many states referred to as the “Comprehensive Assessment and Review for Long Term Care Services” (CARES). Once a person applies for eligibility, the CARES assessment will be triggered, and the level of care that is then approved depends largely on how many of the six main activities of daily living the applicant needs assistance with. If the applicant needs help with three or more activities of daily living, then the highest level of care will be approved for either nursing home eligibility or for care at home. Care at home would then be paid for, in part or fully, under the auspices of various Medicaid-funded, community-based home care programs.
In addition, a physician’s diagnosis of “severe dementia” for Alzheimer’s and other dementia patients is also sufficient to trigger the same kind of Medicaid financial aid.
There are physicians’ and nurses’ Plans of Care, both acting as tools that either the patient’s primary care physician or the home healthcare agency’s supervising nurse normally creates to cater to the continuum of care that the patient will need in the coming period.
For people receiving care at home, the physician’s Plan of Care lists:
- The patient’s needed services
- The type of services needed, i.e. whether “skilled nursing agencies” (referred to as home healthcare agencies), or “non-medical homecare agencies” (known simply as homecare agencies); in addition, whether the patient also needs physical or occupational or other therapy services
- The frequency needed for these services
- Any medical equipment that may be needed (e.g. Oxygen or walkers or wheelchairs)
- The results that the physician expects from these services
For people receiving care at home from a regular (non-medical) homecare agency, the nurse’s Plan of Care is the governing document, and it flows again from the physician’s Plan of Care and from the nurse’s assessment. It provides direction for each patient’s individualized needs. More specifically, it calls for:
- A continual communication with the caregiving staff, whether skilled nursing staff or homecare nurses’ aides and certified nursing assistants (CNAs)
- It delineates each specific task that the patient needs regular assistance with, and it assigns specific staff to render those tasks, whether caregivers or, in some instances, family members
- It requests daily documentation of services rendered, i.e. a medical record that serves to trigger and continue receiving benefits from third parties (without that daily record, there would be no proof that services were actually provided)
In this Part II:
- We’ll meet Mary and trace her progression through the medical services she was provided first as a hospital inpatient, then at a rehabilitation center, and finally, in Part III of this narrative, back home where she is currently receiving care services from both home health and home care agencies. Our interlocutors in this section are Mary herself, her daughter Sally, and Jeffrey, owner of the home care agency that helped them. Jeffrey’s role essentially is to shed light on the transpiring developments.
- And we’ll see how some ADLs and IADLs apply to Mary, providing in particular descriptions for environmental, communication and mobility issues.
Hello, my name is Mary. Last July I celebrated my 81th birthday with my grandkids. I have always been independent. I love driving my car, but now prefer to stay off the highways. It doesn’t bother me though because everything I need is close by.
I really don’t remember how I fell. One moment I was getting up from my chair. I think my leg just gave out, and the next thing I knew, I was lying on the tile, unable to get up. I called out for help. It was lucky my daughter Sally was visiting me here at home. I remember she came running from the kitchen and, after helping me to a sitting position, called 911.
Oh gosh, when I came into the room and saw Mom there on the ground, I panicked. She could barely move, and she was moaning with lots of pain. Later, the hospital scanned Mom, and the doctor confirmed what we already feared: Mom’s hip was broken, and she needed surgery as soon as they could get it organized.
After the surgery, Mom was moved to a nursing home where she was supposed to regain some strength. She had regular physical therapy sessions and slowly began to walk again. The social worker from the nursing home began asking us about what kind of support Mom would have when she got home. Honestly, I hadn’t even begun to think about that. She suggested we meet with a homecare agency to find out what kind of assistance they could provide through a homecare assessment.
When Mary was first admitted to the hospital, a Case Manager was promptly assigned to her. Normally, Case Managers consist of either a social worker or a registered nurse, and their prime function is to gather all the information from the various doctors and nursing providers, keep the patient’s family informed, and ensure that proper case coordination is maintained.
A hospital’s Case Manager can be an amazing source of information and assistance to the patient and their family. They have access to all that the community can offer by way of services, e.g. who is best placed to contact for a particular type of service, or where to go for that other type. They also have first-hand experience dealing with available medical supply companies, ambulance services, and the various organizations that provide homecare services, be those skilled or just for caregivers.
And when time came to transfer Mary to the skilled nursing part of the nursing home (yes, most nursing homes have a skilled nursing section for rehabbing a patient post-surgery), they would book Mary a bed at a close-by home and ensure that a Case Manager there receives Mary’s medical records and is fully ready to receive Mary at the appointed day and time.
I stayed nearly three weeks at the nursing home. I was aching to go back to my own home, but my supervising doctors decided that I shouldn’t go home until I could at least make a few steps on my own, using a walker. My daughter Sally agreed, I guess because what she feared the most was that I would fall a second time again at home.
Anyway, I had physical therapy every day at the home. It was painful at first, and always tiring, though over the days I started doing things that I naturally hadn’t been able to do after my fall. That kind of therapy helped me mostly regain my strength, while visits from an occupational therapist taught me primarily how to better go about getting dressed, shower, and do other things by myself.
Mary’s Case Manager at the nursing home assigned a home healthcare agency to follow-up with Mom once she went back home, and she gave me a list of half a dozen homecare agencies to contact to get a caregiver to help Mom at home. That’s how I met Jeffrey whose agency was on the list. He promptly suggested to come meet both Mom and I at the home. He was very kind, and genuinely wanted to know how he could help us. He talked about evaluating Mom’s ADL’s and began asking us questions about her daily life.
I met and chatted with Sally and Mary for a few minutes and got to know them a little before starting to fill out my 3-page assessment form. This had every conceivable question that could be of interest in delivering the home care for Mary at her home:
- Her projected performance with her activities of daily living
- Her current list of medications
- Address and phone number of her primary care physician, her case Manager at the hospital where she’d been, her pharmacist, and nearest relatives
- Her likes and dislikes in regard to a companion who would be likely to spend a considerable amount of time with her
- And several questions about her past profession, current habits, hobbies, church and other affiliations, and the like
I then made an appointment with Sally to go and visit Mary’s home where my interest would revolve on environmental and safety issues around the house. Here, more specifically, is what I wanted to ascertain for myself:
- Environmental safety
This can impact many aspects of Mary’s daily living activities. As people normally move throughout the day, they make countless decisions about risk and mitigation. When a woman decides to put on a coat because the weather has turned cold, or remembers to turn off a stove burner to prevent fires, she is maintaining her own environmental safety. Sometimes, illness or injury affects a person’s ability to either maintain or recognize aspects of environmental safety.As people age it sometimes becomes harder to maintain a home. If balance and mobility are compromised, it can be difficult to take out the trash, or move larger objects out of walkways. Recognizing how the environment affects safety and independence in a very important factor in an ADL assessment.
- Physiological health risks
Is Mary’s home free of vermin or mold? Sometimes mental or physical illness prevents a person from addressing clear health risks. With many aging individuals, hoarding is a tendency that can worsen as cognition declines. Understanding that excessive collection of things should be treated with empathy and great care is an important step toward improving environmental safety concerning extensive clutter.
Can Mary navigate hallways free of clutter, and get assistive devices like walkers through doorways? Many people do not think about whether a walker will fit through a doorway, until the time comes to use one. A home that at first looks inhospitable may be ideal with a few changes like doorway modifications and ramps. Removing floor runners and rugs helps eliminate potential tripping hazards. Clinicians and health systems often spend considerable time determining if the environment will assist in the healing process or be a risk factor to hospital readmissions.
- Accessing areas
If Mary returns home, will she be able to access the kitchen and bathrooms? Bathrooms are notoriously high fall-risk areas in the home. Adding grab bars, anchored securely into studs helps improve stability while going in and out of the shower. And toilette risers with handles may offer support to continue toileting independently. Having access to nutritious, prepared food is an important consideration. Care should be taken to provide meal alternatives if cooking devices are no longer accessible.
- Other environmental hazards
Does the current environment provide the necessary oversight and support Mary needs to thrive? Some medical conditions limit a person’s ability to maintain their own environment on an intermittent or regular basis. Having regular staff support within calling distance may help support environmental safety. Different types of facilities offer varied levels of care and support, and they may be what is needed to live as independently as possible. Bringing outside caregivers into a private home can also be an important step in creating environmental safety.
- How someone can impact their environment
Sometimes environmental safety, another IADL, is about how a person impacts their environment rather than the other way around. Changes in behavior, aggressiveness, sleep patterns, cognition, and physical abilities may impact an individual’s appropriateness for an environment. Residents in an assisted living are fairly independent, particularly with intermittent staff support as needed. If residents need more memory assistance, or require one on one care, they may no longer be appropriate for the environment, and further modification or intervention may be needed.
Communication, another IADL, is fundamental to human interaction. It encompasses a wide variety of concepts from using technology to indicating the need for basic functions like eating, drinking, and eliminating. Managing calendars and appointments and sharing updates with family members all fall under the category of communication.
Changes in cognition can have a profound effect on a person’s ability to communicate. Sometimes dementia and traumatic brain injuries can damage the parts of a person’s brain that control the ability to use language. Some physical injuries or conditions impact the ability to use language and body gestures:
- Can Mary call for help in an emergency?
Safety is always a top concern when evaluating ADLs. If a person is unable to call for assistance in an emergency, then environmental safety is compromised as a result of communication barriers. Sometimes communication barriers are a result of cognitive decline. When that point is reached, more oversight may be necessary. Using assistive devices can sometimes mitigate physical barriers to communication. Tools like medical alert systems, hearing impaired phones, and hearing aids can help a person maintain independence while ensuring communication and safety is protected.
- Does Mary require assistance to make appointments for required health checks?
Physical and mental impairments may keep people from managing a calendar or setting appointments. For some people, keeping a large calendar with clearly marked dates and appointment times creates a greater sense of control and order.
- Can Mary form and understand words to communicate her needs and feelings?
Depending on physical or mental impairments, patients may have trouble indicating hunger and thirst, elimination needs, or other basic necessities. Illnesses like Alzheimer’s, Parkinson’s, and other dementias can substantially impact a person’s communication proficiency. It is important to assess a person’s communication strengths and weaknesses.
- Are there changes in Mary’s ability to participate in conversations?
Connection and companionship are important human needs. Communication impairment can alienate people from regular activates and relationships and can lead to withdrawal, isolation, and depression. Creating Care Plans that support social interaction and communication at the level a person is comfortable with is an important activities of daily living assessment function. It is important to thoroughly evaluate why a patient is experiencing difficulty communicating and get to the bottom of how that difficulty can be mitigated, even partially.
The communication questions were a little annoying. Any person with half a brain can see I can manage my own business. We did agree it would be helpful to have a shared calendar, so one place would have all the appointments I have coming up.
Jeffrey’s visit and questioning revealed that Mom’s single story home had an accessible bathroom and kitchen, and that with some outside support and light home modifications she could return home safely.
You may have noticed that I refer to nursing aides in the “she” form. That is a professional trait borne from the fact that, at least in care at home, the vast majority of caregivers are female. It is different in living institutions where the genders often divide more equally.
The three parts of the above article took Mary through a tour of the various services that were provided for her, first at the hospital and rehab center, and then at her own home. At first, Mary needed her home aide for long daily shifts, since she couldn’t ambulate easily and needed assistance with shopping and meal preparations, as well as bathing and other personal care services.
But Mary is mentally alert with little or no signs of cognitive decline, other than in the normal aging process. Once she regains some of her strength, she will cut down on the number of hours she needs an aide for, perhaps all the way down to four hours a day, five or six days a week, a typical schedule for an octogenarian who is mentally and physically in relatively good shape.