1 Start 2 Complete OUTCOME MEASURES SURVEYHome Care Partners and Parkinson’s Foundation Community Partners in Parkinson’s CareAs a Community Partner with the Parkinson’s Foundation, Home Care Partners is committed to educate and prepare care staff to provide optimal care for people with Parkinson’s disease (PD) directly in their home. The goal of this survey is to measure, over time, your lived experience with PD. As your Home Care Partner, I will be the facilitator of this survey.Because symptoms of Parkinson’s change over time, we will ask you these questions every 6 months until April 2027 or as long as you are a client of this home care agency. Please provide your Client #: * Please select if this is this persons 1st, 2nd, 3rd, etc. time being surveyed. * Select1st2nd3rd4th5th Does the person with Parkinson's experience the following?: * Mild. Consistent forgetfulness with partial recollection of events and no other difficulties. Moderate memory loss, with disorientation and moderate difficulty handling complex problems. Mild but definite impairment of function at home with the need for occasional prompting. Severe memory loss with disorientation for time and often to place. Severe impairment in handling problems. Severe memory loss with orientation preserved to person only. Unable to make judgments or solve problems. Requires much help with personal care. Cannot be left alone at all. None Over the past month, did the person with Parkinson’s experience: * Vivid dreaming “Benign” hallucinations with insight retained Occasional to frequent hallucinations or delusions; without insight; could interfere with daily activities Persistent hallucinations, delusions, or florid psychosis. Not able to care for self. None Does the person with Parkinson’s have problems swallowing or choking on food? * No problems with swallowing, and does not choke Problems with swallowing, but rarely chokes Problems with swallowing and occasionally chokes Problems with swallowing requiring soft food. Unable to swallow and has a nasogastric or gastrostomy tube Does the person with Parkinson’s have slowness or difficulty using utensils or cutting food? * No slowness or difficulty using utensils or cutting food A little slow or clumsy, but able to feed self without help Slow and clumsy. Needs help cutting some types of food Someone must cut food, but is able to feed themselves Unable to feed self Does the person with Parkinson’s have difficulty turning in bed or adjusting the sheets? * No difficulty turning in bed or adjusting the sheets A little clumsy and slow with turning in bed and adjusting the sheets, but does not need help Only able to turn or adjust the sheets with great difficulty Able to start turning, but unable to do it without help Unable to turn in bed or adjust the sheets without help Does the person with Parkinson’s have problems with falling? * Does not fall Rarely falls Occasionally falls, but less than once a day Falls an average of one time per day Falls an average of more than one time per day Does the person with Parkinson’s have freezing while walking? * “Freezing” occurs when you are unable to walk for a few seconds because your feet seem to be stuck to the ground. Does not have “freezing” Rarely has “freezing” when walking Occasionally has “freezing” when walking Frequently has “freezing” when walking. Occasionally falls because of the “freezing” Frequently has “freezing” when walking. Frequently falls because of the “freezing” Has the person with Parkinson’s walking changed? Is it difficult to walk? * Walking and arm swing have not changed Doesn’t swing arms or tends to shuffle Has a moderate amount of difficulty with walking, but usually don’t need assistance Has severe problems with walking and usually needs assistance Can’t walk at all, even when someone tries to help Has the person with Parkinson’s seen any rehabilitation professionals in the past 2 months? * PT OT SLP Did the person with Parkinson’s go to the emergency room or get admitted to the hospital within the last 30 days? * Choose below and provide a reason. Yes No List Reasons Has the person with Parkinson's received Parkinson's specific resources to be used in the event of an emergency room visit or hospitalization? * Yes No Please list resources: * For Family Care partners: Has someone talked to you about the importance of PD medications on time every time? Yes No Do you feel confident enough to care for your loved one when professional care staff is not present? Yes No Please Clarify Do you feel the home care agency staff visiting your home have the knowledge and skill to work with people with Parkinson’s? Yes No Please Comment Leave this field blank
