General information Yes No N/A
1. Has relevant personal information been gathered?

  • Name
  • Date of birth
  • Legal state of residence
  • Health status, including medications being taken
  • Marital status
  • Family members available for support
  • Name, phone number, and address of attorney, physician, geriatric care manager or other advisor
2. Has financial situation been assessed?

  • Income from Social Security, pension, employment, or other source
  • Expenses
  • Assets
  • Liabilities
Long-term care planning Yes No N/A
1. Is the need for long-term care imminent?
2. Are assets sufficient to cover long-term care needs?
3. Have ways to fund long-term care been reviewed/evaluated?
4. If homeowner, has home equity as a use of funds been discussed?
5. Are long-term care insurance benefits available?
6. Have various housing options and their costs been considered?

  • In-home care
  • Living with a relative
  • Continuing care retirement community
  • Assisted living
  • Nursing home
Insurance planning Yes No N/A
1. Is adequate health insurance available?

  • Medicare
  • Medigap
  • Private health insurance
  • Prescription plans
2. Have Medicaid planning goals and strategies been considered?
3. Has Medicaid qualification criteria been discussed?
4. Has the need for long-term care insurance been established?
5. Is long-term care insurance coverage available to the client?
6. Have existing long-term care insurance policies been reviewed/evaluated?
7. Does long-term care insurance coverage need to be upgraded?
8. Do long-term care benefits need to be accessed?
Estate planning Yes No N/A
1. Has long-term care planning been coordinated with estate planning needs?
2. Have appropriate estate planning documents been prepared?

  • Will
  • Trust
3. Have advanced medical directives been prepared?

  • Durable power of attorney
  • Living will
  • Health-care proxy
4. Have letters of instruction been prepared?
5. Has this information been communicated to family members?
Other Yes No N/A
1. Has the need for organizing important documents and records been discussed?

  • Bank account records (statements and passbooks)
  • Monthly bills to be paid
  • Stock certificates, bonds, and other investment records
  • Retirement plan statements
  • Real estate deeds, mortgages, and other property ownership records
  • Vehicle titles
  • Business agreements
  • Insurance policies
  • Will, trust, advanced medical directives, letters of instruction, and other documents
  • Birth certificate, marriage certificate, divorce decree, military service papers