Premier Home Health Care
Transitional Care
Visits List
FALL RISK and LACE Assessment
Validation
1
Fall Risk Assessment
2
LACE
Please select "Yes" or "No" for following core elements:
Age 65+
Patient's age
Yes
No
select "Yes" or "No"
Diagnosis (3 or more co-existing)
Includes only documented medical diagnosis
Yes
No
select "Yes" or "No"
Prior history of falls within 3 months
An unitentional chane in position resultin in coming to rest on the ground at lower level
Yes
No
select "Yes" or "No"
Incontinence
Inability to make it to the bathroom or commode in timely manner. Includes frequency, urgency, and/or nocturia
Yes
No
select "Yes" or "No"
Visual impairment
Includes but not limited to, macular degeneration, diabetic retinopathies, visual field loss, age related changes, decline in visual acuity, accomodation, glare tolerance etc.
Yes
No
select "Yes" or "No"
Impaired functional mobility
May inlcude patients who need help with IADLS or ADLS or have a gait or transfer problem.
Yes
No
select "Yes" or "No"
Environmental hazards
May inlcude but not limited to poor illimunitation, iapproprirate footwearing
Yes
No
select "Yes" or "No"
Poly Pharmacy (4 or more prescription - any type)
ALL PRESCRIPTIONS including prescriptions for OTC
Yes
No
select "Yes" or "No"
Paint effecting level of function
Pain often effects and individual's desire or ability to more or pain can be facto in depression.
Yes
No
select "Yes" or "No"
Cognitive impairment
Could include patients with dementia, Alzheimer's or stroke patients.
Yes
No
select "Yes" or "No"
LACE test for readmission risk
Has the patient been hospitalized within past 3 months
Yes
No
select "Yes" or "No"
Step1. Length of Stay
Length of stay (including day of admission and discharge)
Step2. Acuity of Admission
Was the patient admitted to the hospital via the emergency department? if yes, enter "3", otherwise enter "0"
Step 3. Comorbidities
Select Yes or No for conditions
Previous myocardial infarction
Yes
No
Cerebrovascular disease
Yes
No
Peripheral vascular disease
Yes
No
Diabetes without complications
Yes
No
Congestive heart failure
Yes
No
Diabetes with end organ damage
Yes
No
Chronic pulmonary disease
Yes
No
Mild liver or renal disease
Yes
No
Any tumor (including lymphoma or leukemia)
Yes
No
Dementia
Yes
No
Connective tissue disease
Yes
No
AIDS
Yes
No
Moderate or severe liver or renal disease
Yes
No
Metastic solid tumor
Yes
No
None (If you will select yes, everything else will be dicarded)
Yes
No
Step 4. Emergency department visits
How many times has the patient visited an emergency department in the six months prior to admission (not including the emergency department visit immediately preceding the current admission)?
What is the Diagnosis
Cardiac NonCHF Clinical Pathway
Cardiac CHF Clinical Pathway
CJR Clinical Pathway
COPD Clinical Pathway
DM Clinical Pathway
Pneumonia Clinical Pathway
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1
Validation states
2
Alerts
3
Payment Info
4
Other Info
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