Caregiver Needs Assessment Survey

August 24, 2004

Dear Friend,

In 2005, the Area Agency on Aging will develop a new four-year Area Plan. In preparing for this assignment, the Agency decided to focus on needs of our local family caregivers. Caregivers are defined as persons aged 60 years of age or older who are family or friends.

This Area Agency on Aging has designed a survey to assess the needs of caregivers to enhance our knowledge and improve our capacity to meet the needs. The Agency now has funding to serve caregivers.

You will find the survey on this website. You can complete and submit the survey on this website. A Spanish language survey is available by contacting the Area Agency on Aging office. For those of you who prefer using a pencil, you can click the link below to download the printable pdf, fill it in and mail to the address below.

Please contact joyce ellen lippman, Area Agency on Aging Director, if you have any questions or comments. She can be reached at 528 S. Broadway, Santa Maria, CA 93454, via phone at 925-9554 or via email at seniors@kcbx.net.
Many thanks for your assistance. Have a great day.

Sincerely,

Leon Mountain, President
Board of Directors

Colleen McLean, Chair
AAA Advisory Council

About this Survey

We are interested in learning about the recent, current and future caregiving responsibilities of people in our community. Family caregivers are an important component in the ability of older persons to maintain their independence and live in their home and community. Even if you have no caretaking responsibilities for an older adult over the age of 60 at this time, we would like your help in planning programs to make the lives of current and future caregivers easier. We are seeking your input; so PLEASE take a few minutes to complete our survey.

SECTION I - ABOUT YOU
Please tell us a little about yourself whether or not you currently have caregiving responsibilities.

SECTION II ADULT AND OLDER ADULT CAREGIVER NEEDS
Complete Section II if you provide care or supervision for one or
more adults aged 18-59 with a health problem or disability or any
adult age 60 or older.

This survey will be analyzed to develop a snapshot view of the caregiver needs within the two-county area of San Luis Obispo and Santa Barbara Counties. With this survey we will be attempting to identify the needs of caregivers including, but not limited to:

All individual responses are anonymous and will be kept strictly confidential.

Please return your completed questionnaire by September 30, 2004 to: Area Agency On Aging, 528 South Broadway, Santa Maria, CA 93454. If you have any questions, please feel free to contact us. Thank you for your time and cooperation.

A PDF Version is also available if you prefer to print it out and mail it to us.

Leon Mountain, President
Board of Directors

Colleen McLean, Chair
AAA Advisory Council

joyce ellen lippman
Area Agency on Aging Director
805.925.9554, seniors@KCBX.net

The Survey

SECTION 1: ABOUT YOU
1 Your gender:
2 Your age:
3 Your race/ethnicity: (Please check all that apply) White (not of Hispanic origin)
Hispanic/Latino
African American/Black
Asian/Pacific Islander
American Indian/Alaskan Native
Other
4 Your marital status:
5 Your total annual household income:
6 What town or city do you live in?
7 What is your current zip code?
8 Do you currently, or have you in the past, cared for an adult family member or friend with a health problem or disability or any adult age 60 or older? (Please check all that apply.) Adult(s) aged 18-59
Adult(s) aged 60 or older
I have not cared for an adult with a health problem or disability or an older adult.
9 Do you anticipate needing to care for an adult family member or friend with a health problem or disability or any adult age 60 or older in the NEXT FIVE YEARS?
10 How many adults do you anticipate providing for in the future? # of adults

PLEASE READ

If you have cared for any adult age 18 or older with a health problem or disability or any adult age 60 or older, proceed to Question 11 and tell us about the adults you cared for. Otherwise, skip to Question 28.

SECTION 2: ADULT AND OLDER ADULT CAREGIVER NEEDS
11 How many adult family members or friends with a health problem or disability or adults age 60 or over do you (or have you) provided care for? # of adults
12 How are these persons related to you? (Please check all that apply.)

Spouse/Partner
Mother or Father
Mother-in-law or Father-in-law
Grandparent
Son or Daughter (over age 18)
Other Relative
Friend or Neighbor
Other (please specify)

13 a. Do any of these persons live in San Luis Obispo County?
b. Do any of these persons live in Santa Barbara County?
14 Do any of these persons live with you?
15 What kind of assistance do you provide? (Please check all that apply.)

Cooking, laundry or house cleaning
Home Maintenance or repair
Transportation
Interpreter
Feeding, bathing, toileting, dressing or grooming
Assistance in transferring
Administering Medications
Managing the person's financial affairs
Direct financial support
Providing emotional reassurance
Arranging and monitoring outside help or services
Other (specify)

16 Overall, approximately how many hours do you spend caregiving or supervising this person(s) in a typical week?
17 Overall, how much money do you spend caregiving or supervising this person(s) in a typical month?
18 Which of these problems have you experienced as a result of your caregiving responsibilities? (Please rate each problem as a major problem, a minor problem, or no problem.)
    Major Problem Minor Problem No Problem
a. Finding trained & reliable home care providers
b. Finding affordable residential care
c. Finding services
d. Having enough money to pay for care
e. Understanding government programs such as Medicare, SSI, or In-Home Supportive Services (IHSS)
f. Finding out about legal options
g. Getting cooperation & assistance from other family members
h. Dealing with a break down in care arrangements
i. Getting information about the illness/disability of the person(s) I care for
j. Ensuring the care recipient's safety
k. Identifying available transportation resources
l. Finding culturally-sensitive resources
m. Communicating with professional resource providers
n. Doing end-of-life planning
o. Balancing other family responsibilities, e.g., children
p. Dealing with dangerous, unwanted, or difficult behaviors of the care recipient
q. Involvement in decisions about the care recipient's medical treatment
r. Modifying my home to meet care requirements
s. Adjusting my work schedule, meeting my work responsibilities
t. Meeting my personal needs such as personal time, exercise
19 To what extend do you experience the following problems as a result of your caregiving responsibilities? (Please rate the extent of each problem as not at all, some, quite a bit, or a great deal.)
    Not at all Some Quite a bit A great deal
a. Physical strain/fatigue
b. Financial strain
c. Emotional upset, guilt
d. Interference w/social life
e. Interference w/family relationships
f. Interference w/free time
g. Interference w/work
h. Physical health changes
i. Reluctance to ask for help
j. Unappreciated
k. Other (specify)
20 To what extent do you agree/disagree with the following statements? (Please rate whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with each statement.)
    Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree
a. I have more caregiving responsibility than I can handle comfortably.
b. I don't have enough time for myself due to my caregiving responsibilities.
c. I cannot get a restful nights sleep.
d. I have a good balance between work, family & personal responsibilities.
e. I am doing a good job of meeting work, family & personal responsibilities.
f. I feel in control of the important things in my life.
g. I feel confident in my ability to handle my personal problems.
h. I feel that any difficulties are up so high that I cannot overcome them.
i. Other (specify)
21 Approximately how many full or partial scheduled workdays did you miss during the past 12 months due to your caregiving responsibilities?

If not applicable, please proceed to Question 24.
22 During the past 12 months, have you considered a reduced work schedule because of your caregiving responsibilities?
23 During the past 12 months, have you considered taking an early retirement as a result of your caregiving responsibilities?
24 Do you have the help you need:
    Yes No
a. In the morning?
b. In the afternoon?
c. In the evening?
d. At night?
e. On weekends/holidays?
f. In a crisis situation?
25 Which of the following resources do you currently use, or would you find useful if they were available? (Please check all that apply.)
    Currently Use Would Use
a. Workshops/seminars on adult care issues
b. Brochures, pamphlets, or other written information
c. Internet references on caregiving
d. Caregiver support group/counseling
e. Help locating services
f. Legal consultation
g. Mediation services to aid in caregiver family disputes
h. Equipment/home adaptation
i. Help determining long term care options
j. Help with admitting care recipient to long term care facility
k. Social support following the death of the care recipient
l. Other (please list)
26 Which of the following work-related benefits do you currently use, or would you find useful if they were available? (Please check all that apply.)
    Currently Use Would Use
a. Ability to adjust work schedule to fit care responsibilities
b. Ability to work at home
c. Part-time work or job sharing
d. Ability to use accrued sick leave to help an ill family member
e. Ability to take up to 12 weeks unpaid leave w/out loss of benefits, to care for an ill family member
f. Ability to use sick/vacation time donated by other employees
g. Dependent care assistance account (tax deductions for adult care expenses)
h. Long term care insurance to cover family members
i. Health coverage for domestic partners
j. Flexible "cafeteria style" benefit plan that allows use of benefit dollars for adult care expenses
k. Employee Assistance Program (EAP)
l. Adult day care center at work
m. Subsidized respite care
n. Health promotion activities such as exercise
o. Other (specify)
27 What community and/or in home services do you currently use, have used or would you find helpful if they were available? (Please check all that apply.)
    Have used Currently use Would Use*
a. Adult Day Care
b. Adult Protective Services
c. Care Management
d. Chores or heavy housekeeping
e. Counseling
f. Education/training
g. Employee Assistance Program (EAP)
h. Financial Assistance (rental help, tax relief)
i. Form completion/letter writing
j. Home Health Care
k. Home Delivered Meals
l Home Repair services
m. Hospice
n. Health promotion, e.g. exercise
o. Home security, e.g. emergency alert
p. Housekeeping
q Information Service
r. In Home visiting
s. In Home Services/Respite Registry
t. Legal Services
u. Money Management
v. Nutrition education/counseling
w. Placement Assistance
x Personal Care, e.g. bathing
y. Respite Care
z. Shopping assistance
aa. Support groups
bb. Translation services (bilingual services)
cc. Transportation/escort
dd. Other (specify)

* Assume the service was available at either an 'affordable' cost or by donation.

If you need information about available senior services, call the Area Agency on Aging at 965-3288, 925-9554, 541-0384 or 1-800-510-2020.
28 Please provide any additional comments you might have about your past, present, and anticipated caregiver needs.