1 MANUAL FOR PROVIDERS OF COMMUNITY REHABILITATION SERVICES RECEIVING SUBVENTION AND / OR OFFERING MEDISAVE USE 5 August 2
2 CONTENTS COMMUNITY REHABILITATION SERVICES PAGE Objectives 2 Key Definitions 2. Definition of Rehabilitation 2.2 Role of Community-Based Rehabilitation Centres 3 Provisions of Care 4 SECTION A: ACCESS TO CARE 4. Criteria and Referrals for Admission 4.2 Outcomes of Referrals 3 5 SECTION B: APPROPRIATE CARE 3 5. Approach to Care Programmes & Services Staffing and Qualifications Patient Assessment Patient Care Care Plan and Treatment Records Care Outcomes Care Reviews Patient Discharge 7 5. Service Contract 8 6 SECTION C: INDIVIDUALISED CARE PLANNING 8 7 SECTION D: SAFE PATIENT CARE 9 7. Policies, Procedures and Patient Safety Areas Medication Safety 9 8 SECTION E: QUALITY ASSURANCE 8. Adverse events and Incidents 8.2 Regular Evaluations 9 SECTION F: PHYSICAL ENVIRONMENT AND AMENITIES SECTION G: PUBLIC HEALTH AND EMERGENCY PREPAREDNESS SECTION H: ADMINISTRATIVE POLICIES AND PROCEDURES. Attendance Rosters.2 Fee Schedules and Charging.3 Means-Testing.4 Financial Management 2 SECTION I: REPORTING AND AUDITS 2 2. Submission of Data on Service Indicators Clinical, Operational, Administrative and Financial Audits 2 ii
3 ANNEXES Page Annex Modified Barthel Index (Shah, Vanclay and Cooper, 989) 4 Annex 2 Suggested List of Additional Standardised Outcome Measurement Tools 7 Annex 3 Rehabilitation Programme Review Form 8 Annex 4 Reference List of Rehabilitation Equipment and Furniture 22 Annex 5 List of Performance Indicators to be Submitted 24 Annex 6 Medisave Audit Cover Note 26 iii
4 . OBJECTIVES COMMUNITY REHABILITATION SERVICES. This manual states the requirements for organisations that are receiving MOH subvention or Medisave use for the provision of community rehabilitation services..2 The manual would be reviewed regularly in accordance with developments in rehabilitation care. 2. KEY DEFINITIONS 2. Definition of Rehabilitation 2.. Patients affected by a variety of medical conditions may require rehabilitation in order to complement or complete their medical care. The aim of rehabilitation is to improve the patient s functional status to the maximum level medically possible, and hence allow them to remain active in the community Medical conditions which may require rehabilitation include, but are not limited to, stroke, Parkinson s disease, orthopaedic conditions such as fractures, post-amputations etc., as well as de-conditioning due to other medical conditions. The process of rehabilitation consists of patient assessment, target setting, therapy, and evaluation of outcomes Rehabilitation must be provided within the context of care for the whole person to ensure that rehabilitation and overall care provision in a community rehabilitation setting is holistic. The manual covers community rehabilitation services for elderly and adults who have functional limitations. 3. PROVISIONS OF CARE 3. The provision of holistic care in a community rehabilitation programme is outlined in nine sections (Section A to I) within this manual. 4. SECTION A: ACCESS TO CARE 4. Criteria & Referrals for Admission 4.. The Agency for Integrated Care (AIC) is the central co-ordinating body for the placement of patients to intermediate and long-term care services. All patients receiving government subsidies for community rehabilitation services must be referred through AIC. The AIC referral forms can be downloaded from the AIC website at: This is distinct from maintenance exercises to maintain functionality and independence. The aim of maintenance exercises is to prevent deterioration of physical and mental functions.
5 4..2 Subsidies and Medisave: For patients who wish to receive government subsidies and/or utilise Medisave for rehabilitation, the Centres/ Providers must assess the patients eligibility and suitability for the rehabilitation programme. Centres must inform AIC of the assessment outcome for patients receiving subsidies. For fresh admission into a rehabilitation programme, all patients who wish to receive government subsidies and/or make Medisave claims must be referred by a Singapore Medical Council-registered medical practitioner 2 who will certify that the patient is suitable and can benefit from rehabilitation to improve his/her functional status. Centres shall work with AIC and the referring source and/or medical practitioner to ensure that the necessary forms documenting the patient s medical condition and co-morbidities is available during referral, including medical diagnosis, certification for rehabilitation, information on their home environment and information of patient s caregivers. A 6-monthly review and re-certification of the needs and suitability of the patient for rehabilitation are required to determine the necessity for the patient to continue the rehabilitation programme (See also Item 5.8: Care Reviews) Additional Criteria for Medisave Use for Rehabilitation: Medisave use will not be allowed for day care or maintenance programmes. Medisave use is for patients who require day or outpatient rehabilitation services to recover functional ability after an acute medical illness, injury, surgery or chronic disuse (e.g. Hip fracture, Stroke, Traumatic Brain Injury, Deconditioning). Medisave is not claimable for rehabilitation carried out to address chronic degenerative conditions without potential for significant functional recovery, congenital disabilities or sports injuries Referral Processes: Centres/ Providers should have written referral processes, specifying acceptable referral sources for non-subsidised patients who are not referred through AIC. The referring source should complete a written form to be submitted to the Centre/ Provider. The form should contain the following components: i. Reason for referral (i.e. type of service required) ii. Client s personal particulars iii. Social information / history iv. Medical information / history, including diagnosis, medical conditions, investigations, management to-date, medications and drug allergies v. Screening (i.e. any infectious disease, fitness to undergo rehabilitation, special precautions) vi. Current functional status vii. Preferences viii. Details of referring person / agency 4..5 Transfers: For subsidised patients who are transferring from one centre to another, the transferring centre must raise the AIC referral form and 2 Where applicable, the referral may also be made by an Advance Practice Nurse (APN). 2
6 submit all the required supporting documents (including original referrals from medical practitioner) through AIC. Subsidised patients who have not been re-certified by a medical practitioner in the last 6 months prior to the transfer would need to obtain an updated certification for suitability and eligibility for rehabilitation. AIC should be informed of the outcome of all AIC referrals. AIC should also be provided with a monthly report of the number and outcomes of referrals from other sources, nonsubsidised or walk-in cases, and all discharged cases for the month. The referral forms, reply forms and monthly report templates can be downloaded from the AIC website at: Admissions: For all patients, admission is contingent upon the approval of the care team. However, patients should not be denied admission to community rehabilitation services based on the medical conditions listed in Table, unless deemed by the medical professionals not to be able to benefit or cause disruption to the rehabilitation/ care of other patients. Table : Admissions for Patients with Medical Conditions MRSA (Colonised) Accept Psychiatric / Dementia Accept stable psychiatric / dementia patients Cardiac / Respiratory Accept patients with stable cardiac / conditions respiratory conditions who are certified to be suitable for rehabilitation. Pulmonary Tuberculosis Accept treated and old PTB patients who are not infectious Cancer Accept HIV positive Accept Hepatitis Accept Nasogastric / Gastrostomy Accept feeding Urinary catheter / Supra-pubic Accept catheter care Colostomy care Accept 4..7 Centres/ Providers should be open to all patients who require their services, regardless of race, language or religion. 4.2 Outcomes of Referrals 4.2. The Centre/ Provider should always inform the referring source of the referral outcome Acceptance by Centre/ Provider: If a patient is found suitable for rehabilitation, the Centre/ Provider should inform the patient, patient s family, referring agency or medical practitioner of the expected enrolment date to the centre Refusal / Rejection by Centre/ Provider: If the patient is not suitable for rehabilitation, the Centre/ Provider must inform the patient, patient s caregiver, referral agency or medical practitioner indicating the reason 3
7 for rejection. Centres/ Providers should assist to make appropriate referrals to alternative relevant organisations should the patient require it Withdrawals by Patient or Family: In addition to informing the referral agency or medical practitioner, centres should make an assessment and record the most likely reason/s for withdrawal. Centres/ Providers should assist to make appropriate referrals to alternative and relevant organisations should the patient require it Temporary Exclusion: Should a patient exhibit disruptive or unmanageable behaviour and acute medical illness, he/she can be temporarily excluded from the rehabilitation services. Centres/ Providers should assist to make appropriate referrals to relevant organisations should the patient require it. Patients who have been temporarily excluded for more than 2 months will be deemed discharged and will require re-certification / new referral from their medical practitioner (see also item 5.9.: Patient Discharge) Efficient Referrals: Patients suitable for rehabilitation should be enrolled for care to start in a timely fashion. Should a patient require referrals to alternative and relevant organisations, this should be completed in a timely fashion. 5. SECTION B: APPROPRIATE CARE 5. Approach to Care 5.. Trans-Disciplinary Approach: In addition to a holistic, patient-centred approach, it is expected that the care approach be multi-disciplinary, where necessary, for good patient care. The therapist should have regular case discussions with other healthcare professionals on the medical and rehabilitation needs of their patients. This can be conducted through telephone, written memos or on-site discussions. Centres/ Providers should also communicate and coordinate with medical practitioners or other healthcare professionals like speech therapists, dieticians, orthotics and prosthetic specialists, podiatrists etc, to provide holistic rehabilitative services and referrals. Centres/ Providers should also link their patients and their caregivers with other service providers for additional areas of needs such as social work, case management, meals-on-wheels, home help, escort services and day care services, as appropriate Evidence-Based Care: Centres/ Providers should aim to ensure that care provided is consistent with current best practices. 5.2 Programmes & Services 5.2. Centres/ Providers providing community rehabilitation services must provide session-based rehabilitation services that include Physiotherapy and Occupational Therapy. The list of physiotherapy and occupational therapy services should include, but are not limited to: 4
8 i. Physiotherapy (i) (ii) (iii) Physiotherapy services are provided to restore or maximise an individual s physical functions which have been limited by illnesses or disabilities. The physiotherapist shall assess the patient s mobility status, physical strength, joint motion, cardiopulmonary endurance, balance, fall risk and pain level. Physiotherapy services may include: Functional mobility training and gait training; Active and passive exercises to improve or restore range of motion, physical strength, flexibility, co-ordination, balance and endurance; Treatment to relieve pain, such as through electro-physical agents; Advice on the use of assistive ambulatory devices such as walking aids and prosthetic devices; Caregiver training and patient education. Community integration activities ii. Occupational Therapy (i) (ii) The occupational therapist shall assess the patient s activities of daily living (ADL), instrumental activities of daily living (IADL), leisure abilities, functional status, cognition, perception and psychosocial status. Occupational therapy services may include: Re-training in ADL and IADL; Exercises and graded activities to improve strength and range of motion, particularly in the upper extremities; Co-ordination and dexterity activities; Advice on the use of orthosis, prosthesis or assistive / adaptive devices to maintain or improve ADL performances; Pre-vocational and vocational training; Advice on occupational ergonomics; 5
9 5.3 Staffing and Qualifications Home assessment and recommendations on home modification; Leisure and recreational therapy; Caregiver training and patient education; Wheelchair and seating assessment. Community integration activities 5.3. Centres/ Providers providing community rehabilitation services are required to have sufficient allied health staff to meet the rehabilitation needs of all patients at all times. Core care staff includes therapists, therapy assistants/aides and healthcare attendants Qualified therapists (physiotherapists and/or occupational therapists) are key to improving the patient s functional status. Therefore, the physiotherapy and occupational therapy programme for each patient must be under the charge of qualified physiotherapists and occupational therapists. The therapy can be provided by the qualified therapists and a team of therapy aides under their supervision. Centres may use alternative modes of employment (e.g. part-time, contract or temporary) or any other arrangement to maintain a staff complement required to meet the standards of patient care required at the Centre. 5.4 Patient Assessment 5.4. Assessment of patients: During the first attendance at the Centre/ Provider, the physiotherapist and/or occupational therapist must conduct a comprehensive initial assessment of the patient which must include an evaluation of the patient s rehabilitation needs based on assessment findings and the information provided by the referral source. Upon completion of the initial assessment, an individualised care plan must be developed (see also Item 6.2: Individualised Care Plans). 5.5 Patient Care 5.5. During each rehabilitation session, the therapist must provide adequate direct therapist to patient contact, i.e. assessment of patient and provision of therapy. Unauthorised and/or untrained personnel e.g. volunteers should not be allowed to carry out therapy for the patients. Caregivers may assist during the therapy exercises or practice as part of care-giver training, but must be supervised by the therapist. 5.6 Care Plan and Treatment Records 5.6. Care Plans must be individualised to the patient (see also Item 6.2: Individualised Care Plans). The service provider must maintain a case file for each patient, containing his/her rehabilitation care plans and 6
10 5.7 Care Outcomes treatment records. The treatment records should document the treatment provided at each session and regular progress updates by the therapist. Suggested assessment tools which may be used in the design of care plans for patients is attached in Annex (Modified Barthel Index) and Annex 2 (other suggested tools) The Centre/ Provider must monitor each patient s rehabilitation outcomes using the Modified Barthel Index (MBI). A copy of the MBI is in Annex. Assessment using the MBI should be done by the attending therapist and repeated at least every 3 months or when the patient s status changes. The MBI scores of all patients receiving subsidies and/or utilising Medisave for rehabilitation programmes must be reported to MOH via the Intermediate and Long-Term Care Information System (ILTC-IS) every quarter. Centres may choose to supplement the MBI with other standardised outcome measurement tools as part of its own outcomes assessment if desired. A suggested list of additional standardised outcome measurement tools is in Annex Care Reviews 5.8. Review and re-certification of the needs and suitability of a patient for rehabilitation are required to determine the necessity for the patient to continue rehabilitation. Details of the reassessment schedule can be found in Figure. This re-certification must be done by the attending therapist and supported by a registered medical practitioner 3. The form for the 6-monthly screening and care review is available in Annex 3. Centres/ Providers should refer the patient back to his primary care physician or the referring physician. Where neither is available, Centres/ Providers should refer the patient to a medical practitioner in the event the patient exhibits red flags while undergoing the rehabilitation programme. Month Admission st Reassessment Window 2 nd Reassessment Window Figure : Reassessment Schedule for Community Rehabilitation Centres/ Providers 5.9 Patient Discharge 5.9. The patient is discharged from the Centre s/ Provider s rehabilitation programme when one or more of the following conditions are met: 3 Where applicable, the re-certification may also be supported by an Advance Practice Nurse (APN). 7
11 i. The patient has achieved his/her rehabilitation goals (therapy goals), and/or the medical practitioner has certified that continual rehabilitation for the patient will not lead to further significant functional improvement; ii. iii. The patient has defaulted attendance or not been able to attend rehabilitation programme (e.g. admission into hospitals/ nursing homes) for more than 2 months. If the patient wishes to return to the rehabilitation programme, he/she will be considered as a new admission and must seek a re-certification 4 or new referral from a medical practitioner; The patient is admitted to hospitals or institutional care such as nursing homes for more than month Procedures for discharge should include developing a discharge or transition plan, encompassing: i. A discharge summary stating the reason(s) for discharge, place to be discharged to and recommendations for continuing care. A copy of the discharge summary should be made available to the patient and/or family to provide to his/her primary care physician or referring institution, where appropriate. ii. Referral to an appropriate agency for patients who are found to be unsuitable for the Centre s services. Arrangements should be made to transfer the patient records to ensure continuity of care. 5. Service Contract 5.. A written service contract should be made between the Centre and the patient and/or family before the patient is admitted. It is important that the patients and/or the family understand and accept the terms and conditions of the service. The service contract should include: i. Nature of the service; ii. iii. iv. Expected frequency of services; Date of commencement; Indemnity clauses; and v. Payment scheme, where applicable. vi. Explanation of discharge criteria (see also Item 5.9 Patient Discharge) so that family understands that the rehabilitation program does not continue indefinitely (i.e. discharge planning). 6. SECTION C: INDIVIDUALISED CARE PLANNING 4 i.e. returning to the centre for screening and assessment before going to the medical practitioner with the review form for endorsement. 8
12 6. Throughout care delivery, Centres/ Providers should respect and promote the patient s autonomy, independence and dignity. Whenever possible, preferences and views of the patient and his/her caregiver should be respected and incorporated into care planning (see below). 6.2 Individualised Care Plans (ICPs): Once a patient s rehabilitation needs are identified from the initial assessment, an individualised, patient-centric care plan must be developed. An individualised care plan should include: i. Patient s identified care needs, strengths, limitations and potential; ii. iii. iv. Specific intervention plans with respect to the patient s needs and goals; taking into consideration where possible, preferences and views of the patient and his/her caregiver; Specific, measurable, attainable outcomes, with time frame for reviews and outcome measurements stated. (Examples of outcome measurement tools can be found in Annex 2); Specific roles and guidance for the care team with respect to the patient s intervention plan, and following any reviews/outcome measurements; v. Specific roles of the patient, family/caregiver and volunteers with respect to the patient s intervention plan; vi. Discharge and transition plans, including specific criteria for discharge or transfer. 6.3 Centres/ Providers should be secular in their approach and be respectfully mindful of the religious affinity of each patient in the provision of care. All Centres/ Providers should have policies and procedures regarding the prohibition of proselytising by staff and volunteers. 6.4 Communication & Patient Education: The aim and approach to care, the patient s care plans and rehabilitation goals, the role to be played by patients and caregivers, should be explained to the patient and his/her care giver. Information and health education should be provided to help the patient and his/her caregiver to manage the patient s care. 6.5 Centres/ Providers must respect the privacy and confidentiality of all patientrelated information. 7. SECTION D: SAFE PATIENT CARE 7. Policies, Procedures, Patient Safety Areas 7.. Centres/ Providers should have policies, procedures or programmes in place to ensure that patient care is safe and protected against adverse outcomes. Centres/ Providers must be able to monitor occurrences/lapses in safety and take appropriate remedial action, for 9
13 example by implementing a system of incident reporting to monitor adverse incidents (see Item 8.: Adverse Events & Incidents) Key patient-safety areas for consideration in the rehabilitation setting are falls and injury prevention Infection control should also be ensured through standard contact precautions and good hand hygiene practices Centres/ Providers must ensure that patients are not subject to physical, emotional, psychological or sexual abuse, or neglect. 7.2 Medication Safety 7.2. The provision of medication to patients who require help with medications during rehabilitation/therapy should be seen as providing care within the context of the whole patient. Staff assigned to administer medications should be trained to do so. Centres must be able to monitor the safety of their medication administration processes. 8. SECTION E: QUALITY ASSURANCE 8. Adverse Events & Incidents: Centres/ Providers should have the necessary structures, processes and procedures to detect and review of significant adverse events and incidents. Findings and recommendations of reviews should be implemented in order to prevent future events and incidents from affecting care quality. 8.2 In addition to evaluating its quality of care, the Centre/ Provider should also regularly evaluate other aspects of its operations, including effectiveness of its programmes, adequacy of financial, volunteer, human resource management, etc, as well as its ability to meet any other requirements (see also Item 2.: Submission of Data on Service Indicators). 9. SECTION F: PHYSICAL ENVIRONMENT & AMENITIES 9. The physical environment of the Centre/ Provider should be barrier-free and safe for patients with physical disabilities. For example, there should be adequate ramps, hand-rails, grab-bars, and slip-resistance floors. Doors and walkways should be sufficiently wide to allow a wheelchair, a patient using a mobility aide, or two people assisting a patient to pass through. 9.2 All fittings and equipments in the Centre should be regularly maintained and in good state of repair at all times. A documented schedule of maintenance and/or regular checks for medical/ therapeutic equipments, and appliances should be available. For therapeutic equipments/ appliances that require licensing, the Centre must ensure that the licensing requirements are fulfilled (e.g. license for ultrasound machines). 9.3 A reference list of appropriate rehabilitative equipment for the Centre is in Annex 4.
14 . SECTION G: PUBLIC HEALTH & EMERGENCY PREPAREDNESS. Centres should put in place appropriate plans in the event of infectious disease outbreaks and/or emergencies. Standard Operating Procedures (SOPs) should include procedures for persons with disabilities, those needing assistance such as patients with dementia and persons on wheelchairs.
15 . SECTION H: ADMINISTRATIVE POLICIES AND PROCEDURES. Attendance Rosters: Centres/ Providers must maintain separate rosters for their clients receiving rehabilitation services and those receiving day care services, as the two services are distinct. This will also facilitate auditing of the two services..2 Fee Schedule & Charging: Every Centre must have a written policy on fee charging. The policy on fee charging should include: i. Administration procedures; ii. iii. iv. Fee schedule; Management of programme fees; Approval and endorsement by Centre Manager / Supervisor / Head of agency..2. For patients from low-income families, the Centre/ Provider should administer means-testing to ascertain the patient s eligibility for Government financial assistance (subsidy)..3 Means-Testing: Every Centre/ Provider must carry out means-testing for every patient requesting for Government subsidy based on the MOH s meanstesting criteria for step-down care to determine the subsidy rate..3. The Approved Centre/ Provider is required to monitor the financial status of all Subsidised Patients and review their financial status at least once a year..3.2 Every Centre/ Provider must provide financial counselling to all Subsidised Patients. Patients must acknowledge in writing that they have been informed of the fees and charges, deposits and any other charges to be paid..3.3 Every Centre/ Provider must provide billing for all Subsidised Patients. The bill shall indicate the amount of the Grant. A sample of the bill format that the Approved Provider will use must be submitted to MOH for approval..3.4 Every Centre must retain the written patient records for a period of three (3) years after the close of the MOH s financial year in which the record was made. 2. SECTION I: REPORTING AND AUDITS 2. Submission of Data on Service Indicators 2.. All Centres/ Providers receiving subsidies and/or making Medisave claims must submit quarterly returns to the Ministry or any other agency designated by the Ministry by the first week following the close of a 2
16 quarter. Quarterly returns must be submitted through MOH s Intermediate & Long-Term Care Information System (ILTC-IS). Further guidance on Service Indicators collected through ILTC-IS is available through the ILTC Desk of Health Information Division, Ministry of Health The list of indicators required is in Annex 5. This list of indicators may be updated or revised by MOH from time to time Centres should submit any other information as and when required by MOH in accordance with the stipulated format, manner of submission and timeline. 2.2 Clinical, Operational, Administrative and Financial Audits 2.2. All Centres/ Providers receiving subsidies and/or making Medisave claims will be subject to regular audit comprising: i. Clinical and Service Audits: This component can include reviewing the rehabilitation programme being provided and ensuring that patients require and are receiving rehabilitation services. Documents bearing the certification/ re-certification from Singapore Medical Council-registered medical practitioner and the therapists assessment would be required. Audits of Individualised Care Plans (ICP) will be conducted to evaluate the quality of care, the qualifications of staff involved in the care, proper documentation, conduct of regular reviews and the discharge criteria. Audits of patient outcomes may also be conducted. ii. iii. Financial Audits: Regular audits of this component are to ensure that the Centre/ Providers are in compliance with MOH subvention and meanstesting framework. Documentation related to both subvention claims and means-testing would be required. Medisave Audits: This is made up of 2 parts, professional audits by MOH and operational audits by CPF Board: (i) The purpose of the professional audit by MOH is to ensure that Medisave claims meet the conditions for Medisave use. The documents required include: Payment records showing the itemised breakdown of the bill submitted for Medisave claim; Hardcopies of the Universal Claim Form (UCF); Patient s individual care plans, or reviewed ICP where appropriate; and Certification/ recertification from Singapore Medical Councilregistered medical practitioner, where appropriate. (ii) The purpose of the operational audits by CPF Board is to ensure that Medisave claims meet the conditions of use. The processes include: The Centre/ Provider s external auditors submitting an Audit Report of Medisave Claims to the CPF Board (see Annex 6) for each financial year. The Audit Report should be submitted within 3 months after the closing of the financial year. 3
17 Regular audits or surprise inspections by the CPF Board of the Centre/ Provider s records. For the purposes of these audits, documents required include: o Hardcopies of the Universal Claim Form (UCF); o Medisave Authorisation Form(s); patient s bills; and o Photocopies of identification papers (where necessary). 4
18 ANNEX MODIFIED BARTHEL INDEX (SHAH, VANCLAY & COOPER, 989) FUNCTIONAL ITEM DESCRIPTION DATE REMARKS FEEDING Dependent in all aspects and needs to be fed Can manipulate an eating device, usually a spoon, but someone must provide active assistance during the meal Able to feed self with supervision. Assistance is required with associated tasks such as putting milk/sugar to drink, salt, pepper, spreading butter, turning a plate or other set up activities Independence in feeding with prepared tray except with cutting meat, opening drink carton, jar lid etc. Presence of another person is not required The person can feed self from a tray or table when food is within reach. The person must put on an assistance device if needed, cut the food, and use salt and pepper, spread butter etc. if desired PERSONAL HYGIENE (GROOMING) Unable to attend to personal hygiene and is dependent in all aspects Asst. is required in all aspects of personal hygiene, but able to make some contributions. Some assistance is required in one or more steps of personal hygiene The person is able to conduct personal hygiene but requires min. asst. before and/or after the operation. The person can wash own hands and face, comb hair, clean teeth & shave. Males must be able to use any kind of razor but must insert the blade, or plug in the razor without asst. as well as retrieve it from the drawer/cabinet. Females must apply own makeup, but need not braid or style her hair DRESSING The person is dependent in all aspects if dressing and is unable to participate in the activity The person is able to participate to some degree, but is dependent in all aspects of dressing Assistance is needed in putting on, and/or removing any clothing Min. asst. is required with fastening clothing eg buttons, zips, bra, shoes, etc The person is able to put on, remove and fasten clothing, tie shoelaces or put on, fasten, remove corset/braces, as prescribed. BATHING Total dependence in bathing self Asst. is required on all aspects of bathing, but the person is able to make some contribution. Asst. is required with either transfer to shower/bath or with washing or drying: including inability to complete a task because of condition or disease etc. Supervision is required for safety in adjusting water temperature, or in the transfer The person may use a bathtub, a shower, or take a complete sponge bath as well as to do all steps of whichever method is employed without another person present Total SCORE for this page 5