Branch-St. Joseph Area Agency on Aging 3C

Key Community Leader

Every three years the Branch-St. Joseph Area Agency on Aging must prepare a Multi-Year Area Plan which documents need and sets priorities for funding and services in our two county planning and service area. Your input will assist us in improving the array of services available to older adults and caregivers. We appreciate your time and input. Thank you!

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* 1. In what county do you reside or work in?

Branch

St. Joseph

Other (please specify)

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* 2. What is your race/ethnicity?

Caucasian/White

African American

Hispanic

Native American

Asian/Pacific Islander

Other (please specify)

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* 3. What is your gender?

Female

Male

Transgender

Prefer not to answer

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* 4. What is your age?

Under 55 years

55-59 years

60-64 years

65-69 years

70-74 years

75+ years

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* 5. Are you:

Married

Widowed

Divorced

Single

Separated

Long-term Partner

Other (please specify)

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* 6. Do you:

Live alone

Live with a spouse

Live with relatives other than a spouse

Live with non-relatives

Other (please specify)

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* 7. The following services are currently available to older adults and caregivers in Branch and St. Joseph Counties. Please rate the services according to the following scale; little need, moderate need, great need, or don't know.

	Little Need	Moderate Need	Great Need	Don't Know
Adult day programs (daytime care of older adults in a group setting)	Adult day programs (daytime care of older adults in a group setting) Little Need	Adult day programs (daytime care of older adults in a group setting) Moderate Need	Adult day programs (daytime care of older adults in a group setting) Great Need	Adult day programs (daytime care of older adults in a group setting) Don't Know
Comments:
Care management/In-home nurse assessment and monitoring	Care management/In-home nurse assessment and monitoring Little Need	Care management/In-home nurse assessment and monitoring Moderate Need	Care management/In-home nurse assessment and monitoring Great Need	Care management/In-home nurse assessment and monitoring Don't Know
Comments:
Caregiver education, support and training (includes support groups)	Caregiver education, support and training (includes support groups) Little Need	Caregiver education, support and training (includes support groups) Moderate Need	Caregiver education, support and training (includes support groups) Great Need	Caregiver education, support and training (includes support groups) Don't Know
Comments:
Caregiver supplemental services (help unique needs of family members who care for a loved one)	Caregiver supplemental services (help unique needs of family members who care for a loved one) Little Need	Caregiver supplemental services (help unique needs of family members who care for a loved one) Moderate Need	Caregiver supplemental services (help unique needs of family members who care for a loved one) Great Need	Caregiver supplemental services (help unique needs of family members who care for a loved one) Don't Know
Comments:
Chore services (shoveling, raking, pest control)	Chore services (shoveling, raking, pest control) Little Need	Chore services (shoveling, raking, pest control) Moderate Need	Chore services (shoveling, raking, pest control) Great Need	Chore services (shoveling, raking, pest control) Don't Know
Comments:
Counseling services	Counseling services Little Need	Counseling services Moderate Need	Counseling services Great Need	Counseling services Don't Know
Comments:
Nutrition education	Nutrition education Little Need	Nutrition education Moderate Need	Nutrition education Great Need	Nutrition education Don't Know
Comments:
Disease prevention/Health promotion	Disease prevention/Health promotion Little Need	Disease prevention/Health promotion Moderate Need	Disease prevention/Health promotion Great Need	Disease prevention/Health promotion Don't Know
Comments:
Friendly reassurance (contact with homebound adults to ensure safety and offer social interaction)	Friendly reassurance (contact with homebound adults to ensure safety and offer social interaction) Little Need	Friendly reassurance (contact with homebound adults to ensure safety and offer social interaction) Moderate Need	Friendly reassurance (contact with homebound adults to ensure safety and offer social interaction) Great Need	Friendly reassurance (contact with homebound adults to ensure safety and offer social interaction) Don't Know
Comments:
Home delivered meals	Home delivered meals Little Need	Home delivered meals Moderate Need	Home delivered meals Great Need	Home delivered meals Don't Know
Comments:
Home repair	Home repair Little Need	Home repair Moderate Need	Home repair Great Need	Home repair Don't Know
Comments:
Homemaker services (laundry, sweeping, dishes)	Homemaker services (laundry, sweeping, dishes) Little Need	Homemaker services (laundry, sweeping, dishes) Moderate Need	Homemaker services (laundry, sweeping, dishes) Great Need	Homemaker services (laundry, sweeping, dishes) Don't Know
Comments:
In-home respite (to provide caregiver a break)	In-home respite (to provide caregiver a break) Little Need	In-home respite (to provide caregiver a break) Moderate Need	In-home respite (to provide caregiver a break) Great Need	In-home respite (to provide caregiver a break) Don't Know
Comments:
Information and assistance	Information and assistance Little Need	Information and assistance Moderate Need	Information and assistance Great Need	Information and assistance Don't Know
Comments:
Legal services (assist with legal affairs including advice, representation, document prep, etc.)	Legal services (assist with legal affairs including advice, representation, document prep, etc.) Little Need	Legal services (assist with legal affairs including advice, representation, document prep, etc.) Moderate Need	Legal services (assist with legal affairs including advice, representation, document prep, etc.) Great Need	Legal services (assist with legal affairs including advice, representation, document prep, etc.) Don't Know
Comments:
Long Term Care Ombudsman Program (advocate for persons living in long term care facilities)	Long Term Care Ombudsman Program (advocate for persons living in long term care facilities) Little Need	Long Term Care Ombudsman Program (advocate for persons living in long term care facilities) Moderate Need	Long Term Care Ombudsman Program (advocate for persons living in long term care facilities) Great Need	Long Term Care Ombudsman Program (advocate for persons living in long term care facilities) Don't Know
Comments:
Congregate meals (group meals at a dining center)	Congregate meals (group meals at a dining center) Little Need	Congregate meals (group meals at a dining center) Moderate Need	Congregate meals (group meals at a dining center) Great Need	Congregate meals (group meals at a dining center) Don't Know
Comments:
Medication management	Medication management Little Need	Medication management Moderate Need	Medication management Great Need	Medication management Don't Know
Comments:
Medicare/Medicaid Assistance Program (MAAP) (healthcare benefits counseling/assistance	Medicare/Medicaid Assistance Program (MAAP) (healthcare benefits counseling/assistance Little Need	Medicare/Medicaid Assistance Program (MAAP) (healthcare benefits counseling/assistance Moderate Need	Medicare/Medicaid Assistance Program (MAAP) (healthcare benefits counseling/assistance Great Need	Medicare/Medicaid Assistance Program (MAAP) (healthcare benefits counseling/assistance Don't Know
Comments:
Personal care (in-home care, bathing, dressing)	Personal care (in-home care, bathing, dressing) Little Need	Personal care (in-home care, bathing, dressing) Moderate Need	Personal care (in-home care, bathing, dressing) Great Need	Personal care (in-home care, bathing, dressing) Don't Know
Comments:
Personal Emergency Response System (call for help button)	Personal Emergency Response System (call for help button) Little Need	Personal Emergency Response System (call for help button) Moderate Need	Personal Emergency Response System (call for help button) Great Need	Personal Emergency Response System (call for help button) Don't Know
Comments:
Transportation (OUT of county)	Transportation (OUT of county) Little Need	Transportation (OUT of county) Moderate Need	Transportation (OUT of county) Great Need	Transportation (OUT of county) Don't Know
Comments:
Transportation (WITHIN county)	Transportation (WITHIN county) Little Need	Transportation (WITHIN county) Moderate Need	Transportation (WITHIN county) Great Need	Transportation (WITHIN county) Don't Know
Comments:

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* 8. How important is it to you that these services be expanded to help you more?

	Not Important	Somewhat Important	Very Important
More services available on the weekend.	More services available on the weekend. Not Important	More services available on the weekend. Somewhat Important	More services available on the weekend. Very Important
More services available in the evening.	More services available in the evening. Not Important	More services available in the evening. Somewhat Important	More services available in the evening. Very Important
More group trips and activities.	More group trips and activities. Not Important	More group trips and activities. Somewhat Important	More group trips and activities. Very Important

Other (please specify)

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* 9. Please rate your level of concern with the following:

	Not Concerned	Somewhat Concerned	Very Concerned
Personal injury	Personal injury Not Concerned	Personal injury Somewhat Concerned	Personal injury Very Concerned
Scams or swindlers, or door-to-door salesmen	Scams or swindlers, or door-to-door salesmen Not Concerned	Scams or swindlers, or door-to-door salesmen Somewhat Concerned	Scams or swindlers, or door-to-door salesmen Very Concerned
Identity theft	Identity theft Not Concerned	Identity theft Somewhat Concerned	Identity theft Very Concerned
Telephone solicitors	Telephone solicitors Not Concerned	Telephone solicitors Somewhat Concerned	Telephone solicitors Very Concerned
Driving	Driving Not Concerned	Driving Somewhat Concerned	Driving Very Concerned
Going out alone	Going out alone Not Concerned	Going out alone Somewhat Concerned	Going out alone Very Concerned

Other (please specify)

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* 10. How do you find out about the services that might help you? (check all that apply)

Area Agency on Aging

Relative, Friend, Neighbor

Television

Newspaper

Radio

211

Community Groups/Clubs

Physician or other health professional

Church

Commission on Aging

Other (please specify)

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* 11. Would you like more information about health insurance?

Medicare A & B (hospital coverage and general medical)

Medicare Part D (Prescription drug coverage)

Medicare Supplements (cover what A & B don't cover, generally)

Medicare Advantage Plans (All inclusive coverage, doctor, hospital, prescriptions)

Low Income Subsidy (helps pay Part D premium and copays)

Medicaid (from the state, for low-income)

Medicaid Savings Plans, QMB, SLB, AMLB (help pay Medicare premiums)

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* 12. If you would like someone to contact you about the health insurance topics you selected in question 11, please provide us with your name and phone number or address and we will contact you. This information will be kept confidential and will not be used for any other purpose.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number