Assessment Domains Screening Tools About this Domain (Screening Tools) In this Domain: HELPS Brain Injury Screen

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1 Screening Tools About this Domain (Screening Tools) Health and human service experts have developed short questionnaires, or screening tools, to help professionals who are not experts in specific fields of expertise identify risks. These screening tools provide a way for you to determine if further expert intervention is/may be warranted. In this Domain: You are provided a number of screening tools designed to help you more deeply explore a concern or suspected concern with the person you are assessing for long-term services and supports. These are not diagnostic tools, and therefore are not determiners of the suspected condition. Rather, these assist you in gathering additional results of the screening(s) to determine the need for a referral for an expert opinion or evaluation. If referrals are determined to be needed, document the need in the respective domain for which the screening tool relates. For example, referrals for further mental health assistance or evaluation would be documented in the Psychosocial Domain within the Referrals question group. HELPS Brain Injury Screen Brain injury is a common problem. Many persons with a brain injury might be undiagnosed. In order to evaluate service eligibility and make appropriate referrals, the source of the disability must be identified. The HELPS screening tool is a first step towards identifying and properly diagnosing a brain injury. H - Have you hit your head or been hit on the head? Note: Prompt client to think about all incidents that may have occurred at any age, even those that did not seem serious: vehicle accidents, falls, assault, abuse, sports, etc. Screen for domestic violence and child abuse, and also for service related injuries. A TBI can also occur from violent shaking of the head, such as being shaken as a baby or child. Last update: 6/12/2017 Page 1 of 19

2 E - Were you ever seen in the Emergency room, hospital, or by a doctor or because of an injury to your head? Note: many people are seen for treatment. However, there are those who cannot afford treatment, or who do not think they require medical attention. L - Did you ever Lose consciousness or experience a period of being dazed and confused because of an injury to your head? Note: People with TBI may not lose consciousness but experience an alteration of consciousness. This may include feeling dazed, confused, or disoriented at the time of the injury, or being unable to remember the events surrounding the injury. P - Do you experience any of these Problems in your daily life since you hit your head? anxiety depression difficulty concentrating difficulty performing your job/school work difficulty reading, writing, calculating difficulty remembering dizziness headaches poor judgment (being fired from job, arrests, fights) poor problem solving S- Any other significant Sickness? Last update: 6/12/2017 Page 2 of 19

3 Note: Traumatic brain injury implies a physical blow to the head, but acquired brain injury may also be caused by medical conditions such as brain tumor, meningitis, West Nile virus, stroke, seizures. Also screen for instances of oxygen deprivation such as following a heart attack, carbon monoxide poisoning, near drowning, or near suffocation. Scoring the HELPS Screening Tool A HELPS screening is considered positive for a possible BI when the following 3 items are identified: 1. An event that could have caused a brain injury (yes to H, E or S), And 2. A period of consciousness or of being dazed and confused (yes to L or E), And 3. The presence of two or more chronic problems listed under P that were not present before the injury. Note: A positive screening is NOT sufficient to diagnose BI as the reason for current symptoms and difficulties Some individuals could present exceptions to the screening results, such as people who do have BI-related problems but answered "no" to some questions Consider positive responses within the context of the person's self-report and documentation of altered behavioral and/or cognitive functioning The original HELPS TBI Screening tool was developed by M. Picard, D. Scarisbrick, R. Paluck, 9/91 International Center for the Disabled, TBI-NET, U.S. Dept. of Ed, Rehab Services Admin, Grant #H128A The HELPS Tool was updated to reflect recommendations by the CDC on the diagnosis of TBI. Helps Brain Injury Screen has been reviewed and updated? Last update: 6/12/2017 Page 3 of 19

4 Assessment of Feet When was their last foot exam? Unknown Month/Year Has the person had surgeries or medical procedures on their feet? Explain: (Displays when option is checked) Does the person have any conditions related to their feet? If was selected, the following questions will be displayed: Conditions and Current Status of Feet: (Check all conditions that apply and indicate the current status): Conditions Problematic Non-problematic Comments Bunions Calluses Corns Fungus Hammer Toes Infection (Cellulitis, Drainage) Open Lesions Overlapping toes Other Other Last update: 6/12/2017 Page 4 of 19

5 Foot Care Needs Apply ointments/lotions Diabetic foot care Dry bandage change Foot soaks Healing Inserts Nails trimmed in last 9 days Pads Protective booties Special Shoes Toe nails need trimming Toe separators Other Other Notes/Comments: (Displays when Other is checked) (Displays when Other is checked) Assessment of Feet has been reviewed and updated? Assessment of Pain Is the person currently experiencing pain anywhere on their body? Explain: (Displays when option is checked) Last update: 6/12/2017 Page 5 of 19

6 If was selected, the following questions will be displayed: How frequently do they experience pain? What is the location of the pain? What is the impact of the pain on their life? Activity Limited Anxiety Depression Fatigue Impairs ability to perform ADLs Irritability Isolation Sleep Loss Other Other Comments: (Displays when Other is checked) (Displays when Other is checked) Indicate the severity of your pain: (Rate 0 = No Pain, 10 = Worst Pain Imaginable) How does the person manage their pain? Notes/Comments: Assessment of Pain has been reviewed and updated? Last update: 6/12/2017 Page 6 of 19

7 Assessment of Sleep Does the person have any concerns about how they sleep? Sometimes If or Sometimes was selected, the following questions will be displayed: Sleep Issues Difficulty waking up Falling asleep Insomnia Nightmares Sleep apnea Snoring Other Other (Displays when Other is checked) (Displays when Other is checked) Comments: Have they had a sleep study completed? Explain: Unknown response Notes/Comments: (Displays when option is checked) Assessment of Sleep has been reviewed and updated? Last update: 6/12/2017 Page 7 of 19

8 Depression Screen (Displays for Ages 19-64) During the last two weeks, have you often been bothered: 1. By having little interest or pleasure in doing things? 2. By feeling down, sad or hopeless? (Displays if is answered to either question #1 or #2 above) Patient Health Questionnaire (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things Feeling down, depressed or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself - or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead, or of hurting yourself in some way Add Columns TOTAL: Last update: 6/12/2017 Page 8 of 19

9 If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? t difficult at all Somewhat difficult Very difficult Extremely difficult For every question answered: Not at all = 0 Several days = 1 More than half the days = 2 Nearly every day = 3 Interpretation of Total Score Total Score Depression Severity 0-4 None 5-9 Mild Depression Moderate Depression Moderately Severe Depression Severe Depression Copyright 1999 Pfizer Inc. All rights reserved. PHQ-9 is adapted from PRIME-MD TODAY. PRIME- MD TODAY is a trademark of Pfizer Inc. Notes/Comments: Depression Screen has been reviewed and updated? Last update: 6/12/2017 Page 9 of 19

10 Geriatric Depression Scale (Displays for Age 65+) During the last two weeks, have you often been bothered: 1. By having little interest or pleasure in doing things? 2. By feeling down, sad or hopeless? (Displays if is answered to either question #1 or #2) Geriatric Depression Scale (GDS) Interview Questions Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive now? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better off than you are? TOTAL GDS SCORE: No Last update: 6/12/2017 Page 10 of 19

11 Scoring: Answers indicating depression are in bold. Score one point for each one selected. A score of 0 to 5 is normal. A score of greater than 5 suggests depression. Source: Sheikh, J.I., & avage, J.A. Geriatric Depression Scale (GDS) Notes/Comments: Geriatric Depression Scale (GDS) has been reviewed and updated? Last update: 6/12/2017 Page 11 of 19

12 Pediatric Symptom Checklist (PSC-17) (Displays for Ages 4-18) Have you or another caregiver ever completed a Pediatric Symptom Checklist form at school or in a physician s Office? - ask the parent/caregiver to complete the Pediatric Symptom Checklist Unsure - ask the parent/caregiver to complete the Pediatric Symptom Checklist Pediatric Symptom Checklist (PSC-17) Symptom Never (0) Sometimes (1) Often (2) Fidgety, unable to sit still Feels sad, unhappy Daydreams too much Refuses to share Does not understand other people's feelings Feels hopeless Has trouble concentrating Fights with other children Is down on him or herself Blames others for his/her troubles Seems to be having less fun Does not listen to rules Acts as if driven by a motor Teases others Worries a lot Takes things that do not belong to him/her Distracted easily Column Totals: Total Score: Last update: 6/12/2017 Page 12 of 19

13 Each item on the 17 question screening tool is scored as follows: Never = 0 Sometimes = 1 Often = 2 Add up the scores in each column to get the total score. The maximum score = 34 How to score items left blank: If 1-3 items are left blank, each is scored 0. If 4 or more items are left blank, the questionnaire is invalid. Assessment Domains Total Score of 15 or higher and suggests the need for further evaluation by a qualified health (M.D., R.N.) or mental health (PhD, LICSW) professional. Michael Jellinek, M.D. and Michael Murphy, Ed.D (authors). Child Psychiatry. Bulfinch 351, Massachusetts General Hospital. Boston, MA Notes/Comments: Pediatric Symptom Checklist (PSC-17) has been reviewed and updated? Last update: 6/12/2017 Page 13 of 19

14 Suicide Screen (Displays for Age 13+) Have you thought about hurting yourself or taking your life in the last 30 days? Person unable to respond or refuses to answer If was selected, the following questions will be displayed: Do you have a plan? - contact a mental health professional immediately Unable to respond or refuses to answer Do you have the means or some way to carry out your plan? - contact a mental health professional immediately Person unable to respond or refuses to answer Do you have a time planned that you will do this? - contact a mental health professional immediately Person unable to respond or refuses to answer Notes/Comments: Suicide Screen has been reviewed and updated? Last update: 6/12/2017 Page 14 of 19

15 Alcohol/Substance Abuse/Tobacco/Gambling ALCOHOL USE Do you currently drink alcoholic beverages like beer, wine or liquor? Sometimes Comments: Assessment Domains If or Sometimes is selected, the following questions will be displayed: How frequently do you drink alcoholic beverages? Daily 1-3 times per week 4-6 times per week Once a month or less Rarely Within the last year, has drinking affected your job, family life and friendships or caused legal problems? Explain: Sometimes Explain: (Displays when is checked) (Displays when Sometimes is checked) Last update: 6/12/2017 Page 15 of 19

16 Cage Questionnaire Have you felt you should Cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? Scoring Two or more answers are considered indicative of an alcohol problem. Discuss referral to an alcohol counselor or primary health care provider for follow-up. SUBSTANCE ABUSE Does the person currently use any street/illegal drugs (i.e. methamphetamine, speed, marijuana) or misuse/abuse prescription medications, glue, inhalants, etc.? Sometimes Comments: Last update: 6/12/2017 Page 16 of 19

17 If or Sometimes is selected, the following questions will be displayed: Assessment Domains Within the last year, has your substance use affected your job, family life and friendships or caused legal problems? Explain: Sometimes Explain: Cage Questionnaire (Displays when is checked) (Displays when Sometimes is checked) Have you felt you should Cut down on your drug use? Have people annoyed you by criticizing your drug use? Have you ever felt bad or guilty about your drug use? Have you gotten high first thing in the morning to steady your nerves or to help you feel better (eye opener)? Scoring Two or more answers are considered indicative of a substance abuse problem. Discuss referral to a drug treatment counselor or primary health care provider for follow-up. Last update: 6/12/2017 Page 17 of 19

18 TOBACCO USE Do you use tobacco products? Sometimes Comments: If or Sometimes was selected, the following questions will be displayed: What type of tobacco do you use? Chewing Cigarettes Cigars Pipe Other (Displays when Other is checked) Have you thought about cutting back on your tobacco usage? plans to reduce usage Plans to reduce usage Comments: How much tobacco do you use per day? Less than one pack One pack More than one pack One cigar or pipe More than one cigar or pipe Other (Displays when Other is checked) Last update: 6/12/2017 Page 18 of 19

19 Are there any safety concerns related to your tobacco use? Drops cigarettes/ashes Falls asleep when smoking Smokes when using oxygen Smokes in bed Refuses ashtray Other (Displays when Other is checked) Assessment Domains GAMBLING Lie-Bet Screening Instrument Reference: Johnson, E.E., Hamer, R., Nora, R.M., Tan, B., Einstenstein, N., & Englehart, C. (1997). The lie-bet questionnaire for screening pathological gamblers. Psychological Reports, 80, Have you ever felt the need to bet more and more money? Have you ever had to lie to people important to you about how much you gambled? Answering to one or both of these questions is suggestive of a problem deserving further assessment. Discuss referral to a gambling treatment counselor or primary health care provider for follow-up. Notes/Comments: Alcohol/Substance Abuse/Tobacco/Gambling has been reviewed and updated? Last update: 6/12/2017 Page 19 of 19