Comprehensive Assessments: A Must-Have Evaluation for Your Senior


Perhaps your senior has just gotten home from the hospital following a long stay, surgery, or other medical event. Or maybe they’re ready to be discharged from a sub-acute rehabilitation center. They may even have been living at home awhile, but you notice it’s increasingly difficult for them to function independently, or they’ve said as much themselves.
What do all three of these scenarios have in common? They are all reasons for you to consider a comprehensive assessment for your senior.

What if your senior already had a comprehensive assessment?

It’s possible your senior already had a comprehensive assessment while they were staying at a facility. It’s the responsibility of the social worker or discharge planner to gather information from different disciplines and arrange services before your senior goes home. He or she may already have talked to your senior’s doctors, nurses, or physical therapists to determine how to transition your loved one back to their regular environment.
However, it’s often impossible for them to know firsthand exactly what your senior needs – mainly because they don’t visit the actual environment themselves. And of course, those needs can grow and change, or you may have to tweak them in order for your senior to function optimally.

What’s involved in a comprehensive assessment?

A comprehensive assessment is exactly what it sounds like: an overarching evaluation of your senior’s needs, challenges, and potential pitfalls when it comes to living at home. The items under evaluation can include the purely medical, the psycho-social, and even the spiritual. Here’s a more detailed breakdown of the components of a good assessment:

  • Medical. Includes medications, vision, hearing, bowel and bladder control, as well as age-specific vaccinations and screenings. There may also be discussions about achieving or maintaining a healthy lifestyle (for example, if your senior wants help to quit smoking).
  • Nutritional. Addresses whether the senior’s diet is well-suited to their requirements. It also takes a look at how certain medications might interfere with their diet or vice versa (for example, many drugs that lower blood pressure and cholesterol don’t mix well with grapefruit). Finally, the assessment will see how the senior’s tastes and preferences can be incorporated into any new diet they’re following.
  • Emotional. Looks at mood issues, including the potential for depression and anxiety. Also gauges cognition, including forgetfulness, Alzheimer’s, and general awareness of the environment and understanding various instructions. Treatment for potential issues includes anti-depressant medication, or those that slow cognitive deterioration, as well as therapy or senior day programs.
  • Functional. Screens for the ability to perform certain tasks (such as self-care). Often includes a full gait and balance evaluation and fall risk assessment. Depending on the circumstances, the person performing the assessment may recommend assistive devices for the senior, such as a cane or walker, or physical or occupational therapy visits.
  • Safety-related. Notes any hazards in the home environment; may also analyze social and caregiver support. Considers whether senior abuse or neglect is taking place by anyone coming into the house, including caregivers.
  • Economical. Measures finance or health-related challenges that may make it difficult for the senior to access needed goods and services, or to manage them. Possible solutions include referrals to community resources, social services, naming a family member representative payee or POA (Power of Attorney), and applying to assistance programs such as Medicaid.
  • Terminal. Discusses end-of-life goals and planning if applicable, including advance directives and spirituality. Seeks to provide senior with options that offer the highest quality of life possible after taking into account the senior’s particular medical condition.

Don’t put off getting a comprehensive assessment for your senior

A comprehensive assessment may lead to an individualized care plan – another important piece of the puzzle when it comes to seniors thriving at home. But regardless, don’t put off getting this important evaluation for your senior. Without one, it’s impossible to identify all the risk factors your loved one encounters on a daily basis. However, knowledge is power. Once you know about such challenges, you and your senior can begin facing them – together.
If you are unsure of how to best help an aging loved one, the trained and compassionate staff at the Institute on Aging is here to help you make that decision and gain the best in at-home senior care. Contact us to find out more.

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As we approach the end of #SocialWorkMonth, Institute on Aging would like to take a moment to recognize and celebrate the incredible work being done by all of our Community Living Fund and HomeSafe social workers.

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Sophia became a part of the Community Living Fund team in December 2022, joining at a critical time when additional coverage was required for certain cases. Additionally, CLF was in the process of introducing a new assessment and implementing CalAim services for San Francisco members.

Sophia has been an essential contributor to these ongoing initiatives while effectively managing a caseload of Intensive Case Management (ICM) clients. We were thrilled to receive positive feedback about her support for the TRCS program, which demonstrates her dedication to the agency's mission. CLF is grateful to have a Case Manager like Sophia, who is passionate about serving San Francisco's vulnerable population.

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Three and a half years ago, Maggie Fang started her journey as an Assessment Specialist in the Support at Home Program at IOA. Her excellent people skills enabled her to manage a caseload of older adults and individuals with disabilities, helping them receive homecare to age in place. Maggie was selected to pioneer the Temporary Respite Caregiver Support program, and we are delighted to have such a skilled and dedicated individual leading our newest program at IOA. Thank you, Maggie, for your exceptional work! 

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