Facility Admission Priority Worksheet (Supervised by an active care consultant [Worksheet])
1. What is the 'number one thing you want to avoid' after admission? (Choose one)
※Once this is settled, your perspective during facility tours will remain focused.
[ ] A. The environment is a poor fit, leading to a loss of vitality (less facial expression, staring blankly during the day, etc.)
[ ] B. Dementia appears to progress (inability to speak, restlessness, etc.)
[ ] C. The person seems distressed and smiles less (feeling like they don't belong, lack of enjoyment, etc.)
[ ] D. Costs are too high, making payments difficult (total amount is unpredictable)
[ ] E. Family members become exhausted and collapse from the burden (distance, communication, and roles are too heavy)
【Current honest feelings/notes】
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
2. 'Essential conditions' you cannot compromise on (up to two)
(Write down priority conditions to resolve the 'thing you want to avoid' chosen in 1.)
Condition 1:
(Example: During the day, there is time spent in the floor area or dining room rather than staying in the room.)
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Condition 2:
(Example: The total monthly cost (including actual expenses) stays within the budget decided by the family.)
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
3. Top 3 things to 'definitely ask' during a tour
※Trying to ask everything will cause confusion.
Narrow it down to three based on your answer to 1.
【Tips for choosing】
If you chose A, B, or C for 1: Include more questions about 'daily life and how time is spent'.
If you chose D for 1: Definitely include questions about 'money (total costs)'.
If you chose E for 1: Definitely include questions about 'communication rules and family roles'.
Question 1: (Example: When the resident's health declines at night, at what stage is the family contacted?)
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Question 2: (Example: What is the average monthly 'actual expense' for things like electricity and hair care?)
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Question 3: (Example: To what extent can the resident's preferred drinks or habits be continued?)
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
4. What the family can do / What is difficult (Drawing the line)
※These are 'important agreements' to ensure the family doesn't burn out after admission.
What you can do (visiting within a reasonable range, accompanying to medical appointments, etc.):
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
What is difficult (areas to leave to professionals, things that cannot be handled due to work, etc.):
＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
5. Monthly budget (estimated total amount)
※Think in terms of the 'total' including additions and actual expenses, not just the 'base fee'.
Monthly total: Up to approx. ＿＿＿＿＿＿ yen