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Expanding Long-term Care Choices for the Elderly

Using Assessment Data


William D. Spector, Ph.D., Senior Social Scientist, Center for Organization and Delivery Studies, Agency for Healthcare Research and Quality, Rockville, MD.

Activities of daily living (ADLs) (e.g., bathing, dressing, eating) and instrumental activities of daily living (IADLs) (e.g., shopping, meal preparation, transportation) are important measures of functional disability and can serve as assessment tools for determining eligibility for long-term Care (LTC) programs, appropriate levels of care, and care planning.

To use ADLs and IADLs as disability indicators, the assessor simply needs to add up the ADLs/IADLs with which the person being assessed needs assistance. The greater number of ADLs/IADLs, the more likely the person being assessed will need a mix of informal and formal long-term supports. The number of IADLs/ADLs with which a person needs assistance will also help determine whether care can be intermittent (less than 20 hours per week), substantial (less than 40 hours per week), full-time (up to 80 hours per week), or around the clock (approximately 100 hours per week). Additional criteria to supplement ADLs/IADLs include: behavioral problems (dangerous to self and others, wandering, hallucinations and delusions), fecal (versus urinary) incontinence, medical and rehabilitation needs, and social functioning.

Matching the level of care to the level of need first requires assessing an individual's disability needs through ADLs/IADLs. Other considerations include:

  • Family members' availability to provide informal care.
  • Instability risk (to determine if the setting in which the person is to receive services is flexible enough to add services as necessary).
  • Cost.
  • Client preference.

Several States use one assessment tool across LTC settings:

  • Washington developed the Comprehensive Adult Assessment tool, which is used for assessing people age 18 and over to determine eligibility for all residential settings. The State is currently studying how to expand this tool for use with people with mental disabilities and children with special health care needs.
  • Maine developed a uniform tool in the early 1990s to be used in assessing the need for either nursing facility or home care (in addition to the Minimum Data Set). The State is examining how to use this tool for other residential settings.
  • North Carolina and Missouri are developing uniform tools to be used across settings, as part of a project sponsored by the Agency for Healthcare Research and Quality. The modular instrument has a core set of questions/indicators to be used in all settings; other modules are customized by population.


Spector WD, Fleishman JA. Combining activities of daily living with instrumental activities of daily living to measure functional disability. J Geron Soc Sci 1998;53B(1):546-57

Spector WD, Fleishman JA, Pezzin LE, et al. The characteristics of long-term care users. Rockville (MD): Agency for Health Care Policy and Research, Department of Medicine, John Hopkins University, Urban Institute. AHRQ Publication No. 00-0049, January, 2001.

Spector WD, Reschovsky JD, Cohen JW. Appropriate placement of nursing-home residents in lower levels of care. Milbank Q 1996 Apr;74(1):139-60.

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