Center for Disability Advocacy Rights (CEDAR)
841 Broadway, Suite 605
New York, New York 10003
(212) 979-0505
"Q-TIPS" - TIPS ON PREPARING THE M11q
© 2000
The M11q is the only part of the home care assessment process in which someone speaking on behalf of the client states why he or she needs home care. The doctor's M11q must give a complete picture of the client's needs and justify the amount of care requested. Now with Task-Based Assessment (TBA) and Cluster Care, detail is even more important in the M11q. If 24-hour care is requested, the M11q must explain what the night-time needs are and WHY sleep-in OR split-shift care is needed. Here is a page by page guide to the M11q.
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PAGE 1 OF M11q | |
| LANGUAGE ON M11q | TIP |
| "How long have you treated this patient?" | Opinion of doctor who has treated patient for a long time is more persuasive - make sure completed |
| "Date of this examination" | Make sure doctor SIGNS the M11q less than 30 days after the last exam AND you FILE the M11q within 30 days after the doctor EXAMINED client AND signed M11q |
| A. CURRENT CONDITION
DIAGNOSES CHRONIC CONDITION/ DETERIORATION OF PRESENT FUNCTION LEVEL EXPECTED |
Make sure ALL diagnoses are listed, even
ones this doctor is not treating -
anything that contributes to functional need M11q asks to check if deterioration expected. Since condition must be med-ically stable, note that condition is stable, no sudden deterioration expected, no need for frequent medical or nursing judgment to determine changes in plan of care |
| B. HOSPITAL INFORMATION - expected date of discharge |
If in hospital, note date READY for discharge, even if not expected |
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Page 1 of M11q - continued C. MEDICATIONS | |
| LIST OF MEDICATIONS | In "frequency" - state time of day as well as "QID" - state if MUST have assistance at night, before bedtime |
| Indicate patient's ability to take medication: | THIS PART OF FORM IS A TRAP!! The definition of "self-administer" is not what most doctors and others think. |
| ____ can self-administer | Can check "can self-administer" |
| 2. ___ needs reminding 3, ____ needs supervision 4. ____ needs help with preparation
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with any of 2, 3, or 4 - these include
"pre-pouring" of meds by nurse or family into medication box. As long as client can put pill into mouth (or inject insulin, apply eye drops, etc.) if reminded, supervised and assisted by aide who may prompt her as to time, take pill from medication box, put pill into her hand, bring liquids, and "position" her physically for administration, she can "self-administer." Most dementia patients CAN do this. Aide MAY NOT take pill out of a bottle for non-self-directing client - need a pre-counted box. |
| 5. ____ needs administration | THIS should be checked ONLY for PEOPLE WHO CANNOT PHYSICALLY PUT PILL INTO MOUTH (or eyedrops into eyes, inject insulin, etc.). If it is checked, you need to fill in next part: |
| If patient CANNOT self-administer
med,
(a) can s/he be trained...? Yes No |
This should be completed ONLY if client CANNOT put pills, eyedrops, etc. into her body. If so, probably can't be trained, and need to specify whether nurse or family member will give meds. |
| (b) What arrangements have been made for administration of meds? | Even if client CAN self-administer, but needs someone to "pre-pour" meds into weekly medication box, specify WHO will do that. |
| PAGE 2 of M11q - Continued
D. IMPAIRMENTS Check all that apply ELIMINATION * Note "urgency" or "frequency" -- how frequent? -- especially at night if
requesting night care (e.g. hourly) * State reason for symptoms if known (side effect of meds, advised to drink lots of
fluids to prevent infection, diabetes) * State whether needs assistance to remain continent -- (reminding, cueing,
contact guarding, hands-on assistance)(BLADDER OR BOWEL TRAINING
PROGRAM prescribed - aide must remind client every 2 hours to go during day/
night even if no urge * State SPAN OF TIME during which needs assistance - if OK alone at night but
needs help thru bedtime, or needs assist thru night. * If requesting sleep-in or split-shift MUST detail need for toileting at night * Even if continent or occasionally incontinent, write in type of assistance needed
with toileting - that unsafe to use toilet alone because of risk of falling -
unsteady balance, gait, poor judgment - will get up alone at risk, needs
reminding, etc. * If incontinent, state frequency need diaper changes day and night - if history of or particular risk of decubitus condition (bedsores) | |
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Page 2 Con'd -- E. MENTAL STATUS Check those that apply and write in nature, frequency of symptoms, eg. * needs to be reminded to eat, drink, or be talked through steps of dressing, eating, etc; * If client lacks judgment so tries to get up and walk even though physically
prone to falling, needs aide present from getting up, or to assist If check "danger to self or others," wandering, abusive, etc. be sure to state that
these dangers occur only if left alone and that 24-hour live-in care (or whatever
you request) will maintain client's health & safety at home IF CLIENT CAN'T BE LEFT ALONE AT ALL - specify who will stay with client while aide shops/ does laundry, or vice versa | |
| Can client direct a home
care worker?
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If client is not "self-directing," state WHO will direct care - usually a family member, involved neighbor, or community agency. Must be in daily contact and be available 24-hours a day for emergencies (by phone, beeper). Need not live with client. |
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F. MEDICAL TREATMENT If doctor checks these boxes, be sure care is permissible for aide, using guide
below. TIP: If client is in CONCEPTS (consumer-directed program), aide can do
ANY "SKILLED" TASKS. KEY: PCA = personal care aide or home attendants or HHA = home health aides (HHA) If aide can't do task, specify at bottom of page WHO will do the task - nurse or
family member OR if client is enrolled in or applying for CONCEPTS Source: 18 NYCRR 505.14(a), NYS DSS Local Commissioners Memorandum [LCM] 92 LCM-70, "Personal Care Aide Scope of Practice," NYS Dept. of Health Memorandum No. 92-24, "Home Health Aide Scope of Tasks" | |
| 1. Decubitus care | Both PCA and HHA may do routine skin care --
lubricate unbroken stable skin with non-prescription
lotions, powders, creams, do gentle massage of
unbroken skin areas, back rub.
HHA may also inspect skin for signs of pressure/ irritation, and apply prescription topical meds to stable skin surface for self-directing client. |
| 2. Dressings - sterile | only nurses (or trained family members) |
| 2. Dressings - simple | Specify that wound is stable & no medication needed. A "stable" wound is closed skin with no drainage, swelling, infection, or redness, but may have scab or be crusted. PCA may remove old dressing, cleanse skin around wound with soap and water, apply new dressing, but may not apply prescription or nonprescription medication to wound or apply sterile dressing. HHA may apply these medications, but not sterile dressing. |
| 3. Bedbound care (turning, exercising, positioning) | PCAs & HHAs can turn & position & transfer with hoyer lifts. See #5 on exercise |
| 4. Ambulation exercise | OK for PCAs & HHAs. Should check this and write in something like "needs assistance to walk 1 hour/day inside or outside to maintain strength, flexibility, conditioning" to increase hours under task-based assessment (TBA) or cluster care |
| 5. ROM/ Therapeutic exercise | Passive range of motion (where aide moves client's
joints) -- PCA may not, HHA may.
Active range of motion (client does exercise with coaching, aide supports joints) - PCA may |
| 6. Enema | PCA may not. (HHAs may administer commercial, not soap, solutions for self-directing clients). |
| 7-8 Colostomy, ostomy care | PCA may not. HHA may do daily care if ostomy is mature and stable, some irrigation allowed only if client self-directing. |
| 9. Oxygen administration | Oxygen tank - HHA may set up, turn on & off,
check that flow rate is at prescribed rate but may
not set/regulate flow rate, may clean, observe &
record and report. PCA may not
CPAP for sleep apnea - HHA may apply, unclear if PCA may |
| 9. Oxygen con'd | Ventilator (including IPPB) - PCA may not. HHA may, but only for self-directing client, and only if HHA CPR-certified. HHA may plug in, charge batteries, check settings against plan of care, set gauges, may not assess need for suctioning or perform suctioning except superficial oral suctioning with bulb syringe |
| 10. Catheter care | For external and indwelling catheters, PCA may do
daily routine perineal care, empty bag, measure and
record output, and for:
Condom catheter (Texas, external) -- Personal care
aides may apply catheter and change and empty
bag Indwelling (foley) catheter -- PCA and HHA may not
insert or remove. Both may empty the bag, but
PCA may not change the bag. HHA may irrigate
catheter and change the bag only for self-directing
patient. Intermittent or straight catheter -- PCA and HHA may not |
| 11. Tube irrigation | PCA may not. |
| 12. Monitor vital signs | PCA may not measure pulse, blood pressure, or
temperature but may measure and record fluid
intake and output and may weigh client Diabetes tests -- HHA may do finger prick blood test for self-directing client, may do urine sugar test from commode & bedpan generally, but from indwelling catheter only for self-directing client |
| 13. Tube feeding | Nasogastric or gastric tube -- PCA may not. HHA
may not insert or irrigate tube or instill feeding, but
may assemble, clean and store equipment. Neither
PCA nor HHA may do Total Patenteral Nutrition
(thru IV)
Gastrostomy tube feeding - HHA may do for self-directing clients; PCA may not |
| 14. Inhalation therapy | PCA may not instill but may assist client to do herself; HHA may instill for self-directing client. |
| 15. Suctioning | (of tracheostomy) - PCA may not
HHA - ssame as #9 above for ventilator |
| 16-17 Speech/hearing/ occupational therapy | PCA/HHA may not |
| 18. Rehabilitation therapy | see range of motion No. 5 |
| 19. Special dietary needs | "Simple" modified diets - defined as change in one
nutrient (e.g. low fiber, fat, cholesterol, sugar,
sodium, protein, bland), amount of calories (low
calorie) or mechanically altered (soft, liquid,
chopped, ground, pureed). For these PCA may:
* develop menu, prepare grocery list and shop,
prepare meals, assist with feeding (may spoonfeed)
& measure and record intake Complex modified diets - when includes more than one of the changes made for "simple" modified diets - PCA is not supposed to develop menu, prepare grocery list, or prepare meals, but may shop, assist with feeding, and measure & record intake. HHA may do what PCA may not. |
| 20. Other | a. Equipment -- PCA aides may use hoyer lifts, walkers & wheelchairs, assist with braces, splints, slings, elastic support stockings, prostheses, hearing aides, and clean and store (but not remove or clean) artificial eyes, use humidifiers |
| 20. Other con'd | b. Grooming - PCA may clean and file nails only for non-diabetic clients, may apply elastic stockings. May not apply ace bandage. HHAs may cut nails for self-directing clients. |
| Page 3 of M11q
SECTION III -- IDENTIFICATION OF SERVICE NEEDS A. Ability to Ambulate/Transfer | |
| * NEVER check "CAN" if client can't do it alone. If needs assistance of
person, whether verbal or physical, check "CAN WITH ASSISTANCE OF
PERSON" and walker, etc.
The form is confusing - show that a PERSON is needed to assist even if a
cane or walker is used, for additional support. Write in margin that client
CANNOT perform task safely without a PERSON (note BOTH cane and
person are needed). * In margin or on comment page, specify type of assistance needed and
why: e.g. needs "contact guarding" - unsafe to transfer or ambulate
without support and assistance or cueing and prompting by a person
because prone to falling because of gait or balance disorder, dizziness,
arthritis, fracture, Parkinsons, etc. * * GET UP FROM BED - note time gets up and also needs assistance in going to bed at night AMBULATE INSIDE - needs assist all day and evening until goes to bed AMBULATE OUTSIDE - write advised to go outside 1 hr daily to ambulate, get fresh air | |
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Page 3 - Con'd B. CHORE (Clean, laundry, meal prep, shop, reheat meals) & PERSONAL CARE SERVICES NEEDED (groom, dress, wash, bathe, feed,
toilet) Form asks if needs "Total" or "partial" assistance with personal care. This
distinction is meaningless. Under their definition, the only people who need
"total" assistance are those who cannot perform any part of the task alone, but
must have someone perform every part of task. 18 NYCRR 505.14(a)(2). This
limits it to bedbound, incontinent persons. A more common sense definition for
"total" assistance would mean persons who cannot perform the task ALONE
without assistance. Whether that assistance is "cueing and prompting" or full
hands-on assistance. it still takes the presence of an aide. Since the form does
not specify definition, the doctor can use his or her own reasonable definition. This part of the form is a chance to emphasize needs at particular times of day -
FEEDING & REHEATING MEALS -- must be done at dinner time - unsafe to reheat
meal alone; if needs assistance at night with drinking liquids or needs small,
frequent meals (diabetic, prevent UTI's). SPECIAL TOILET NEEDS -- this is another place to indicate urgency or frequency, need for assistance at night or evening, and extent of need | |
| PHYSICIAN's CERTIFICATION & SIGNATURE | Make sure doctor DATES form, clearly writes address, ID number, phone, hospital affiliation, if any |
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COMMENT PAGE * Physician should sign and date comment page in addition to page 3 - even
if it is prepared by a social worker, both should sign it. * Specify the number of hours per day needed and why: The New York
Court of Appeals allowed the State to implement a "gag rule" - a
regulation (18 NYCRR 505.14(b)(3)(i)(a)(3)) that PROHIBITS doctors from
stating the number of hours of care the patient needs. Kuppersmith v.
Perales, 93 N.Y.2d 90, 688 N.Y.S.2d 96 (Mar. 25, 1999), affirming 668
N.Y.S.2d 381 (App. Div. 1st Dept. 1998). However, the doctor may
describe the nature and frequency of the client's needs. EXAMPLE: that
client needs turning and positioning every 2 hours to prevent bed sores,
needs frequent toileting because of high fluid intake or incontinence, needs
frequent assistance at night because of dementia-related sleep disorder and
lack of judgment causing client to try to get out of bed at risk of falling
throughout night. Physician MAY say client should not be left alone, or that needs an awake
aide night and day for specified reasons. In practice, despite this court
ruling, doctors still say needs 24-hour care or "split-shift" care. But must
also state the REASONS why needs care or should not be left alone AT
DIFFERENT TIMES OF DAY - e.g. needs contact guarding and assistance
with ambulation to maintain health and safety and prevent falling, explain
why client prone to falling (unsteady gait, arthritis, poor balance, fracture,
cardiac or pulmonary impairment, etc.), prior history of falls. * Avoid using term "safety monitoring" - specify which ADLs client needs
help with and when - EX. Client who wanders needs cueing and guarding
assistance for safe ambulation at unscheduled times day and night." Client who
leaves the stove on needs "cueing and supervisory assistance with meal
preparation at unscheduled times of day." Preventing falling is NOT "safety
monitoring" but rather is assistance with ambulation because of unsteady gait,
etc. * Indicate times of day when assistance is crucial (bedtime, to give dinner because client can't reheat or prepare meal, to give evening/ night meds, to
assist with toileting & ambulating through bedtime or during the night) * For non-self-directing client, explain who will direct care, prepare
medication box, and if aide can't leave client alone, how outside chores will get
done. * Because of Task-Based Assessment (TBA) & Cluster Care, be sure form SPECIFIES tasks needed such as that client take walks outside daily (or inside | |