| Needs | Scale/assessment items |
| Falls | Prior fall, ADL status, unsteady gait, primary mode of locomotion, making self-understood (cognitive function), or dyspnea [9] |
| Moods | Score of 3 and above in Depression Rating Scale [13] |
| Cognition | Score of 2 and above in Cognitive Performance Scale [14] |
| Social activities | Reduced social interactions |
| Nutrition | Weight loss of 5% or more in last 30 days, or 10% or more in last 180 days |
| Driving review | Score of 3 and above in the Driving Scale [15] |
| ADL capacity | Daily decision making, change in decision making, primary mode of locomotion, change in ADL status, Alzheimer’s disease, dementia other than Alzheimer’s disease [9] |
| Hospital-ER visit | Hospital visit, ER visit, daily decision making, dementia other than Alzheimer’s disease, falls, dyspnea, lonely, unstable conditions, capacity of managing medication, self-reported health, pain frequency [9] |
| Pain | Score of 2 and above in Pain Scale [16] |