How to Prepare for DSHS Care Assessment

The Assessment That Determines Everything

The DSHS CARE assessment is the single most consequential appointment in Washington's long-term care system. It determines functional eligibility for Medicaid-funded home care, how many personal care hours your parent may receive each month, and helps determine which programs they can access. Financial eligibility is reviewed separately. A low score means fewer hours — or no services at all. A score that accurately reflects your parent's true needs can mean the difference between 22 hours of monthly care and over 200.

Most families walk into this assessment unprepared. They assume the assessor will see what they see every day — the struggles with bathing, the confusion with medications, the falls that happen when nobody is watching. But the CARE tool is a standardized scoring instrument, and it measures what happened during a specific window of time using specific clinical terminology. If you do not speak its language, your parent's needs will be under-counted.

How the CARE Tool Scores Your Parent

The Comprehensive Assessment Reporting Evaluation (CARE) tool is administered by DSHS Home and Community Services (HCS) case managers or Area Agency on Aging (AAA) staff. It evaluates four dimensions:

1. Activities of Daily Living (ADLs): Physical ability to perform seven core tasks — bed mobility, transfers, locomotion, eating, toileting, personal hygiene, and bathing
2. Cognitive performance: Memory, decision-making ability, and the ability to make self understood
3. Behavioral symptoms: Wandering, verbal/physical aggression, socially inappropriate behavior, resistance to care
4. Clinical complexity: Medical conditions requiring skilled oversight — diabetes management, wound care, oxygen therapy, catheter care

Each dimension generates a score, and the combined result places your parent into one of 17 classification groups (Group A Low through Group E High). The classification group determines the maximum monthly personal care hours — ranging from 22 hours at Group A Low to 393 hours at Group E High.

The 7-Day Observation Window Is Critical

The CARE tool only counts ADL assistance that occurred at least three times within the seven days preceding the assessment. This is the rule that trips up more families than any other.

If your parent needed help getting out of bed every morning for the past month but happened to have three good days right before the assessment, and the assessor asks about the last seven days, those good days reduce the score. Conversely, if your parent has been hiding their struggles (common with elderly patients who fear losing independence), the assessor will score them based on what is reported, not what the family knows to be true in an average week.

Here is what to do:

Start documenting seven days before the scheduled assessment. Keep a simple log for each ADL:

• Bed mobility: Did your parent need help repositioning, turning over, or sitting up in bed?
• Transfers: Did they need help moving from bed to chair, chair to standing, or in/out of a vehicle?
• Locomotion: Did they need a walker, wheelchair, or physical assistance to move around the home?
• Eating: Did you need to cut food, open containers, feed them, or monitor them during meals?
• Toileting: Did you help them get to the toilet, clean themselves, manage clothing, or manage incontinence products?
• Personal hygiene: Did you help with brushing teeth, hair care, hand washing, or face washing?
• Bathing: Did you help them get in or out of the tub/shower, wash body parts, or dry off?

For each task, note the specific level of help:

• Supervision: You were present and gave verbal cues but did not physically touch them
• Limited assistance: You guided a body part or provided steadying support
• Extensive assistance: You performed part of the task for them (wiping during toileting, washing their back, buttoning clothing)
• Total dependence: You performed the entire task

The distinction between "limited" and "extensive" is where most families lose hours. If you physically wipe your parent during toileting, that is extensive assistance — not limited — and it scores higher. If you fully wash their lower body during bathing, that is extensive. The assessor needs to hear the specific physical actions, not a vague "I help them."

Do Not Let Your Parent Under-Report

Elderly patients frequently minimize their difficulties during the CARE assessment. Pride, embarrassment, fear of losing independence, cognitive impairment that masks awareness of their own limitations — all of these lead to under-reporting.

You have the right to be present during the assessment and to supplement your parent's answers with your own observations. When the assessor asks your parent, "Can you get dressed by yourself?" and your parent says yes, you can add: "In the last seven days, I've had to button her shirt and zip her pants every morning because her arthritis makes those motions impossible."

The assessor is not trying to disqualify your parent. They are scoring based on reported and observed data. Your documented observations are valid data.

Behavioral and Cognitive Points Matter

The CARE tool does not only measure physical ADLs. Behavioral symptoms and cognitive impairment can move your parent into a higher classification group, which means more care hours even if physical ADL scores are moderate.

Document these during the seven-day window:

• Wandering (leaving the home without awareness, getting lost in familiar areas)
• Verbal aggression (yelling, threatening, cursing at caregivers)
• Physical aggression (hitting, pushing, throwing objects)
• Resistance to care (refusing medication, refusing bathing, refusing to eat)
• Socially inappropriate behavior (undressing in common areas, smearing)

For cognitive performance, note instances of:

• Inability to make daily decisions (what to eat, what to wear)
• Short-term memory failure (forgetting a conversation from five minutes ago)
• Inability to make themselves understood (word-finding difficulties, incoherent speech)

Each documented behavioral episode adds points that influence the classification group. A patient with moderate ADL needs but significant behavioral symptoms can land in Group B or higher, with substantially more authorized hours than Group A.

Fast-Track Assessments for Hospital Discharges

If your parent is being discharged from a hospital and needs immediate DSHS services, ask the hospital discharge planner to request a fast-track CARE assessment. The hospital can submit an intake referral to DSHS Home and Community Services (Form DSHS 10-570) to expedite the process.

Under a fast-track agreement (Form DSHS 13-713), DSHS can authorize temporary personal care services for up to 90 days while the full assessment and financial eligibility review are completed. This prevents the gap between hospital discharge and the start of home care services that leaves so many families scrambling.

What Happens After the Assessment

The assessor will place your parent in a classification group and determine a base hour allocation. If the allocation is lower than what your parent needs, you have the right to request an Exception to Rule (ETR) under WAC 388-106-0135. An ETR can authorize hours above the standard allocation for the classification group.

If you disagree with the assessment results entirely, you can appeal through the DSHS Office of Administrative Hearings. The appeal must be filed promptly — the notice of action will include the deadline.

The Hospital-to-Home Transition Guide includes the complete CARE assessment preparation workbook — the 7-day observation log, ADL translation worksheets that map your daily caregiving activities to the CARE tool's scoring levels, and the behavioral documentation forms that capture the data the assessor needs to see.

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