You will need to find out what agencies and facilities provide long term care in the area where you would be most likely to need care, the scope and cost of their services, then fill in the blanks.
The worksheet can be adapted and expanded to fit your situation, but it gives you an organized starting point for gathering information that will help you make the right decision. You can record information for two agencies/facilities per worksheet.
HOME HEALTH AGENCY
Name of Home Health Agency #1 _______________________________ Address _______________________________ _______________________________ _______________________________ Contact Person _______________________________ Phone_________________________ E-mail_________________________ Check which types of care are available and list the cost __ Skilled Nursing Care Cost/Visit $______________ __ Home Health Care Cost/Visit $______________ __ Personal/Custodial Care Cost/Visit $______________ __ Homemaker Services Cost/Visit $______________ NURSING FACILITY _______________________________ Address _______________________________ _______________________________ _______________________________ Contact Person _______________________________ Phone_________________________ E-mail_________________________ __ Skilled Nursing Care Cost/Visit $______________ __ Personal/Custodial Care Cost/Visit $______________ OTHER FACILITY Other possible facility/service #1 (e.g. assisted living, adult day care) ______________________________ Address _______________________________ _______________________________ _______________________________ Contact Person _______________________________ Phone_________________________ E-mail_________________________ What services are available? _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ |
Name of Home Health Agency #2
_______________________________
Address _______________________________ _______________________________ _______________________________ Contact Person _______________________________ Phone_________________________ E-mail_________________________ Check which types of care are available and list the cost __ Skilled Nursing Care Cost/Visit $______________ __ Home Health Care Cost/Visit $______________ __ Personal/Custodial Care Cost/Visit $______________ __ Homemaker Services Cost/Visit $______________ NURSING FACILITY _______________________________ Address _______________________________ _______________________________ _______________________________ Contact Person _______________________________ Phone_________________________ E-mail_________________________ __ Skilled Nursing Care Cost/Visit $______________ __ Personal/Custodial Care Cost/Visit $______________ OTHER FACILITY Other possible facility/service #1 (e.g. assisted living, adult day care) ______________________________ Address _______________________________ _______________________________ _______________________________ Contact Person _______________________________ Phone_________________________ E-mail_________________________ What services are available? _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ _____________________________ Cost $_______________________ |