Table 1.

The CARE Tool Suggested Intervention Based on Identified Impairments

Domain	Measure*	Items	Definition of Impairments- List Impairments	Recommendation If Impaired
Physical function	Falls	Single item of falls in last 6 months	≥1 falls	Weigh risks and benefits of treatment options incorporating information about the patient’s physical performance Consider Physical Therapy (outpatient or home-based depending on eligibility for home care): request gait/assistive device evaluation, strength, and balance training Consider Occupational Therapy (if eligible for home care, referral for safety evaluation): request evaluation and treatment
	Self-rated ECOG performance status	Single item	≥3	If falls specifically - check orthostatic blood pressure and decrease or eliminate blood
	Physical function	Walking 1 block and climbing 1 flight of stairs	Any limitation (a little or lot)	pressure medications if blood pressure is low or low normal. Consider falls prevention handout.
Functional status	OARS IADL	6-items IADL items (walking, transportation, meals, housework, medicines, money)	Any 2 IADL items with “some help” or “unable”	Consider the following potential treatment modifications, particularly in the palliative treatment setting: 1) consider single agent rather than doublet therapy if appropriate 2) modify dosage (eg, 20% dose reduction with escalation as tolerated) 3)
	OARS ADL	3-items ADL items (in/out of bed, dressing, bath/shower)	Any ADL items with “some help” or “unable”	modify treatment schedule if appropriate. Consider frequent toxicity checks (weekly or every other week) Consider Physical Therapy (outpatient or home-based depending on eligibility for home care): request gait/assistive device evaluation, strength, and balance training Consider Occupational Therapy (outpatient or home-based depending on eligibility for home care): request evaluation and treatment for functional impairment
Global health	Fatigue	Single item none to very severe	Moderate, severe, very severe	Provide energy conservation handout Consider providing exercise prescription Consider Occupational Therapy referral for energy conservation and activity management Consider Physical Therapy referral for structured exercise and/or physical activity program
	Pain	Single item 0–10	≥4 pain level	Consider initiation of pain medication(s) if not already prescribed Consider referral to palliative care if already on pain medications which are not adequate
Nutrition	PG-SGA of nutrition short form	Significant weight loss defined Overall PG-SGA scoring	Weight loss: 3% within 3 months or 6% within 6 months PG-SGA scoring, <6, ≥6	Discuss concerns related to nutrition and how potential treatment may impact nutrition Consider recommendations and/or handouts for nutritional supplements, small frequent meals, and/or high protein/high calorie snacks Consider referral to 1) nutritionist/dietician, 2) dentist if poor dentition or denture issues, 3) speech referral if difficulty with swallowing, 4) meals-on-wheels Use caution with highly emetogenic regimens and utilize aggressive anti-emetic therapy
Social support	Medical outcomes survey (MOS) social support 8 item	Instrumental items 1–4	Any item with none, a little, or some of the time	Discuss adequacy of social support at home Discuss who the patient can call in case of an emergency Confirm documented health care proxy is in the medical record Consider referral or information on 1) social worker 2) visiting nurse service or home health aide (if meets criteria)
Psychological	PROMIS anxiety 4-item	Summed 4–20 raw score	Raw score: ≥11	Discuss history of mood issues and treatment history
	PROMIS depression 4-item	Summed 4–20 raw score	Raw score: ≥11	Consider referral to 1) psycho-oncology for counseling, 2) psychiatry if severe symptoms or if already on medications which are not adequate, 3) spiritual counseling or Chaplaincy services, 4) palliative care if other physical and/or cancer symptoms present Consider initiating pharmacologic therapy if appropriate in conjunction with PCP Provide linkage to community resources (such as support groups and local/national buddy or volunteer programs) Assess suicide risk and/or elder abuse if appropriate
Cognitive function	PROMIS cognitive abilities 4-item	Summed 4–20 raw score	Raw score: ≤11	Provide explicit and written instruction for appointments, medications, and treatments Elicit input and perspectives from caregiver(s) about patient’s cognition Assess decision-making capacity and elicit health care proxy information and input if the patient lacks decision-making capacity Consider referral to cognitive specialist (e.g., neurologist or geriatrician) Consider Occupational Therapy referral for cognitive rehabilitation If dementia is suspected, consider neuropsychological testing
Comorbidity	OARS comorbidity	No/yes summed (0–13) Interference for each	≥3 conditions Or any condition with a great deal of interference Specific for any history of diabetes, heart disease, or liver/kidney disease	Initiate direct communication (written, electronic, or phone) with patient’s PCP about the plan for the patient’s cancer Discuss how comorbidities affect risks and benefits of treatments choices Modify dosage or schedule if there is concern about how the patient will tolerate therapy or if there is a concern about worsening of comorbidities If history of diabetes (of any level)- avoid neurotoxic agents if another option is equivalent If history of heart disease (of any level)- consider minimizing volume of agents and/or administer at slower infusion rate If history of chronic liver or kidney disease (of any level)- adjust medication dose as appropriate
	Polypharmacy	# of daily medications	Meds ≥9	Ask patient to bring in prescribed, over-the-counter medications, and supplements to review at the next visit Consider medication review: minimize psychoactive medications including those used for supportive care, minimize duplicative medications, and reduce medicines solely used for hypertension or diabetes if appropriate Consider having pharmacist meet with patient to evaluate drug interactions and medication counseling Recommend pillbox and/or medication calendar
	Hearing	Single item	fair/poor/deaf	Ensure wearing hearing aids if indicated and consider hearing specialist referral
	Vision	Single item	fair/poor/blind	Ensure wearing glasses if indicated and consider vision specialist referral
Social determinants of health	Financial distress	Single item from Patient Satisfaction Questionnaire (PSQ-18)	Strongly agree or agree	Take into consideration cost of necessary medications and/or infusions including insurance coverage and out-of-pocket costs Assess for barriers to acquiring medications Consider referral to social worker and/or financial counselor regarding insurance coverage and costs of medical care
	Health literacy Health numeracy	Two items from brief health literacy screening	Somewhat, a little, not at all Hard, very hard	Simplify communication using plain language and make use of graphics/pictures as appropriate Confirm comprehension of treatment plan to minimize risk of miscommunication Provide explicit and written instruction for appointments, medications, and treatments Provide written instructions (at the sixth grade level) to patient/caregiver regarding the cancer treatment and supportive care plan(s) as well as when initiating new medications Consider assessment of medication adherence
	Transportation	Two items: How much trouble to get transportation? Missed appointments?	Some or a lot of trouble Yes	Provide information on transportation services and ride assistance programs Consider referral to social worker
	Housing	Two items: What is your housing situation?	I do not have housing Yes, worried about losing housing	Provide information on community housing resources as available Consider referral to social worker for assessment of living
		Worried about losing housing?		environment and potential housing alternatives
	Food, utilities, clothing…	Six items addressing specific needs	Yes to any of the following: food, utilities, medicine or health care, clothing	Provide information on community resources and assistance programs (e.g., food stamps, meal delivery, energy assistance, cash assistance) as available Consider referral to social worker for assistance in identifying assistance programs and medical insurance advising (Medicaid) as appropriate

Abbreviations: ADL = activity of daily living; ECOG = Eastern Cooperative Oncology Group; IADL = instrumental activity of daily living; OARS = Older Americans Resources and Services; PG-SGA = patient-generated subjective global assessment; PROMIS = Patient-Reported Outcomes Measurement Information System.