FAIRFIELD CARES HOME HEALTHCARE SURVEY Thanks to The Greater Jefferson County Foundation, City of Fairfield L.O.S.T. grant, and private donors for funding this survey.Fairfield Cares is a non-profit dedicated to building a more responsive system of home health care that supports well-being and independence for senior citizens and those of all ages with needs for health, social, and other services in Jefferson County.The purpose of this survey is to identify the needs and gaps in services and resources for Jefferson County residents who need help of any kind in order to remain safely in their homes for as long as possible.Thank you for taking the time to fill out this survey. Its data is necessary when applying for future grants to help solve this problem.YOU SHOULD COMPLETE THIS SURVEY ONLY IF BOTH OF THE FOLLOWING ARE TRUE:1. You are a resident of Jefferson CountyAND 2. You need or you have needed within the past five (5) years someone to provide ANY of the following services in your home because you have either a temporary or a permanent condition limiting your ability to take full care of yourself. Care from an RN or a CNA Physical or occupational therapy Managing medications or housekeeping Meal preparation, delivery Bathing or toileting Managing money & bills Minor appliance repairs Repairs or upgrades to make your home safe Installation of safety devices House or yard maintenance Grocery shopping or errands Childcare Transportation to appointments Companionship Help accessing physical, social, and mental health resources. CONFIDENTIALITY: Your identity will not be asked for when you take this survey. All your answers will be automatically anonymous.IF YOU NEED HELP TO COMPLETE THIS SURVEYSend your name, phone number, and your question to: surveyhelp@lisco.comWe’ll get back to you as soon as we can.IF YOU COMPLETED A PAPER COPY OF THIS SURVEYPut your survey in the box at one of these locations: Fairfield Public Library, 104 W. Adams St. – On rear of counter Fairfield City Hall 118 S. Main St. – Inside first door Universal Therapy, 1401 S. Main St. – On table of front desk Revelations (Revs) Health Center, 114 N. Main St. Question Title 1. Is Jefferson County IA your primary place of residence? Yes No Question Title 2. What is your age? 0 - 17 18 - 30 31 - 44 45 - 59 60 to 74 75 or older Question Title 3. What type of insurance coverage do you have? Check all that apply. Medicare Medicare Supplemental Insurance Medicaid (Amerigroup, Iowa Total Care, Molina Healthcare) VA - CHAMPVA, Tricare Private Insurance (United Healthcare, BCBS) Long-Term Care Insurance Uninsured Other (please specify) Question Title 4. What is your approximate average household income? $0-$24,999 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000-$149,999 $150,000-$199,999 $200,000 and up Question Title 5. Which of the following health conditions do you have? Mark all that apply. Diabetes Cardiovascular Disease - including but not limited to: Congestive Heart Failure, Arrhythmias, Hypertension, Coronary Artery Disease, Peripheral Artery Disease, Stroke Respiratory Disease - including but not limited to COPD, Asthma, Emphysema Parkinson's Disease Cancer ALS - Amyotrophic Lateral Sclerosis Arthritis Osteoporosis Alzheimer's/Dementia History of falls Blind or poor vision Deaf or limited hearing Poor balance or mobility issues None of the above Other (please specify - such as surgery, chemo, etc.) Question Title 6. Are you homebound? Yes No Question Title 7. Are you disabled? Yes, permanent disability Yes, temporarily disabled No Question Title 8. Do you currently wear a medical alert device? Yes No Question Title 9. How many times have you fallen in the past 12 months? No falls in the past 12 months 1-2 times 3-5 times More than 5 times If yes, have any falls resulted in fractures? Question Title 10. Have you been hospitalized or in a rehab facility within the past year? Yes No Question Title 11. If yes, did someone in the hospital or rehab facility work with you, a family member, and/or another representative to plan your discharge so you could receive the services/resources you needed? Yes No NA - I have not been hospitalized or in a rehab facility Question Title 12. If you received some, but not all of the services you needed, please mark the services you received: Home Health Nurse - catheter care, wound care, colostomy care, IM medications, diabetic foot care, etc. Physical Therapy Occupational Therapy Speech Therapy - includes treatment for swallowing difficulty Social Services Home Health Aide (assistance with bathing/hygiene) Medical equipment (wheelchair, walker, shower bench, grab bars, etc.) NA Other (please specify) Question Title 13. Please check the services you needed but did not receive: Registered Nurse Physical therapy Occupational therapy Speech therapy Social Services Home health aide Medical Equipment NA Other (please specify) Question Title 14. How many people currently live in your household? Question Title 15. If you live with someone, are they able and willing to assist you with any care needs? Yes No NA - I live alone or do not have any care needs Question Title 16. Does anyone else in your household require assistance with any medical needs or activities of daily living? Yes - Please refer them to fill out a survey also. No NA - I live alone Question Title 17. Do you have a pet? Yes No Question Title 18. If yes, do you need help to care for a pet or pets - for example: feed them, take for a walk, clean litter box, take to vet, etc.? Yes No NA - I do not have a pet NA - I have a pet or pets, but do not need help to care for them Question Title 19. Do you currently need assistance with any of the following activities? Check all that apply. Using the telephone Transportation Managing finances Preparing meals Light housekeeping Laundry General home maintenance Mowing Snow removal Trash/recycling None of the above Please specify how often per week assistance is needed for any services checked above: Question Title 20. At any time in the past 5 years, have you been in need of assistance with any of the following activities? Check all that apply. Using the telephone Transportation Managing finances Preparing meals Light housekeeping Laundry General home maintenance Mowing Snow removal Trash/recycling None of the above Please specify how often per week assistance is needed for any services checked above: Question Title 21. Do you currently use any meal delivery service? Such as Mom's Meals, Meals on Wheels, Meal Train, or other meal delivery services. Yes No If yes, what type of meal delivery service do you use? Question Title 22. Do you require assistance with transfers such as getting into/out of bed, chairs, AND/OR your home? Yes No If yes, what specifically do you need assistance with? Question Title 23. Do you need assistance with toileting and toilet hygiene? Yes No If yes, what specifically do you need assistance with? Question Title 24. Do you need assistance with dressing/undressing? Including but not limited to undergarments, shoes, and jacket/coat etc. Yes No If yes, what specifically do you need assistance with? Question Title 25. Do you need any assistance with bathing, whether in the shower/bathtub or sponge bath? Yes No If yes, what specifically do you need assistance with? Question Title 26. Do you need any assistance with managing your medications, setting them up weekly, filling prescriptions, AND/OR remembering to take them at the correct times? Yes No If yes, what specifically do you need assistance with? Question Title 27. On a scale of 0-10, how well do you understand your medications? What they are for, when to take them, side effects, etc. 0 - Not at all 10 - Extremely well Clear i We adjusted the number you entered based on the slider’s scale. Question Title 28. Do you require the use of an assistive device? Check all that apply. If you already have the device, please note. I NEED: I ALREADY HAVE: N/A - DO NOT NEED Cane Cane I NEED: Cane I ALREADY HAVE: Cane N/A - DO NOT NEED Walker Walker I NEED: Walker I ALREADY HAVE: Walker N/A - DO NOT NEED Wheelchair Wheelchair I NEED: Wheelchair I ALREADY HAVE: Wheelchair N/A - DO NOT NEED Electric scooter Electric scooter I NEED: Electric scooter I ALREADY HAVE: Electric scooter N/A - DO NOT NEED Hospital bed Hospital bed I NEED: Hospital bed I ALREADY HAVE: Hospital bed N/A - DO NOT NEED Lift chair Lift chair I NEED: Lift chair I ALREADY HAVE: Lift chair N/A - DO NOT NEED Bed rail Bed rail I NEED: Bed rail I ALREADY HAVE: Bed rail N/A - DO NOT NEED Raised toilet seat/seat riser Raised toilet seat/seat riser I NEED: Raised toilet seat/seat riser I ALREADY HAVE: Raised toilet seat/seat riser N/A - DO NOT NEED Bedside commode Bedside commode I NEED: Bedside commode I ALREADY HAVE: Bedside commode N/A - DO NOT NEED Grab bars Grab bars I NEED: Grab bars I ALREADY HAVE: Grab bars N/A - DO NOT NEED Question Title 29. If you need any assistive devices, do you know where to obtain them? Yes No N/A Question Title 30. If an assistive device is not available to borrow, do you need help to pay for it? Yes No N/A Question Title 31. Are there stairs to enter your home? Yes No Question Title 32. Are there multiple levels inside your home? Yes No Question Title 33. Do you own or rent your place of residence? Own Rent Question Title 34. If you rent, is your house or apartment in good, safe condition? Yes No N/A If no, please specify the problem(s): Question Title 35. Do you need help to get your landlord to make the necessary repairs? Yes No N/A Question Title 36. If you own your own home, is it in need of repairs or modifications to make it safe and livable? Yes No N/A Question Title 37. If repairs/modifications are needed, please check all that is needed and whether or not you can afford to make repairs/modifications: CANNOT AFFORD: CAN AFFORD: N/A - NOT NEEDED: Air conditioning Air conditioning CANNOT AFFORD: Air conditioning CAN AFFORD: Air conditioning N/A - NOT NEEDED: Convert tub to walk-in shower Convert tub to walk-in shower CANNOT AFFORD: Convert tub to walk-in shower CAN AFFORD: Convert tub to walk-in shower N/A - NOT NEEDED: Doors Doors CANNOT AFFORD: Doors CAN AFFORD: Doors N/A - NOT NEEDED: Furnace Furnace CANNOT AFFORD: Furnace CAN AFFORD: Furnace N/A - NOT NEEDED: Insulation Insulation CANNOT AFFORD: Insulation CAN AFFORD: Insulation N/A - NOT NEEDED: Locks Locks CANNOT AFFORD: Locks CAN AFFORD: Locks N/A - NOT NEEDED: Paint exterior/interior Paint exterior/interior CANNOT AFFORD: Paint exterior/interior CAN AFFORD: Paint exterior/interior N/A - NOT NEEDED: Plumbing Plumbing CANNOT AFFORD: Plumbing CAN AFFORD: Plumbing N/A - NOT NEEDED: Railings on stairs - interior/exterior Railings on stairs - interior/exterior CANNOT AFFORD: Railings on stairs - interior/exterior CAN AFFORD: Railings on stairs - interior/exterior N/A - NOT NEEDED: Ramp Ramp CANNOT AFFORD: Ramp CAN AFFORD: Ramp N/A - NOT NEEDED: Roof Roof CANNOT AFFORD: Roof CAN AFFORD: Roof N/A - NOT NEEDED: Safety bars Safety bars CANNOT AFFORD: Safety bars CAN AFFORD: Safety bars N/A - NOT NEEDED: Screens Screens CANNOT AFFORD: Screens CAN AFFORD: Screens N/A - NOT NEEDED: Siding Siding CANNOT AFFORD: Siding CAN AFFORD: Siding N/A - NOT NEEDED: Windows Windows CANNOT AFFORD: Windows CAN AFFORD: Windows N/A - NOT NEEDED: Other (please specify) Question Title 38. If repairs or modifications are needed and you cannot afford to pay for them, do you know where to apply for help to pay for the cost? Yes No N/A - either no repairs are needed or I can afford to make them Question Title 39. Do you need financial assistance for any of the following? Check all that apply. Rental assistance Utility bills Medical bills (other than dental) Dental bills Phone Lifeline (medical alert device) Other (please specify) None of the above Question Title 40. Do you need help to apply for Social Security or SSI? Yes No Question Title 41. Do you need help to apply for a grant or loan for home repairs? Yes No Question Title 42. During the past year, how supported did you feel when you wanted or needed help from others? For example, if you felt lonely and wanted to talk to someone or got sick. Extremely supported Very supported Somewhat supported Not so supported Not at all supported N/A - I have not had any need for help from others Question Title 43. During the past year, how disruptive were your physical health or emotional problems to your normal social activities with family, friends, neighbors, or groups? Extremely disruptive Very disruptive Somewhat disruptive Not so disruptive Not at all disruptive Question Title 44. On a scale of 0-10, how well do you feel you understand your healthcare needs? 0 - Not at all 10 - Extremely well Clear i We adjusted the number you entered based on the slider’s scale. Question Title 45. Would you utilize a Senior Center, Adult Day Care, or similar services if they were available? Yes No Question Title 46. Have you needed assistance related to any intermittent (such as surgery) or ongoing/chronic healthcare needs in the past 12 months? Question Title 47. Have you needed assistance related to any intermittent (such as surgery) or ongoing/chronic healthcare needs in the past 5 years? Question Title 48. How many times have you needed assistance related to a healthcare need in the past 5 years? Question Title 49. If you have required in-home assistance in the past 5 years related to a healthcare need, who paid for those services? Check all that apply. Insurance Private pay/family Church or organization Crowdfunding N/A Other (please specify) Question Title 50. Did someone help you complete this survey? Yes No Done
