Wisconsin's Functional Screen

Wisconsin’s Functional Screen system is a web-based application used to collect information about an individual’s functional status, health and need for assistance for various programs that serve the frail elderly and people with developmental or physical disabilities. The screen is used to determine functional eligibility for certain mental health services, adult long-term care programs and children's long-term support programs. Experienced professionals, usually social workers or registered nurses, who have taken an on-line training course and passed a certification exam are able to access and administer the screen. 

Resources for certified screeners: Adult LTC FS, Children's LTS, MH/AODA, General Resources for all Screeners

General Information

• Overview: Background information on the history and use of the Long-Term Care (LTC) Functional Screen.

• Papers* on testing the validity and reliability of Wisconsin's functional screens:

  • Children's Long-Term Support Functional Screen Validity (PDF, 74 KB)

  • Adult Long-Term Care Functional Screen Validity (PDF, 54 KB)

  * The papers above were prepared as part of Wisconsin's applications to the Centers for Medicare & Medicaid Services for approval of the Children's Long-Term Support and Adult Long-Term Care Functional Screens.

Resources for Certified Screeners Adult LTC FS, Children's LTS, MH/AODA 

Adult LTC FS Screeners

• Wisconsin Adult Long Term Care Functional Screen (F-0036) (PDF, 141 KB; Revised 2/20/12)
• Wisconsin Long Term Care Functional Screen Instructions (Revised 12/5/11) 
• Diagnosis Cue Sheet (PDF, 50 KB; 2/7/11)
• Sample Diagnosis Verification Request (PDF, 5 KB)
• Guidelines for Defining Physical Disability (PDF, 23 KB)
• DD Decision Tree (PDF, 20 KB; Updated 4/11/11)
  • DD Decision Tree Instructions (PDF, 63 KB)
  • DD Case Analyses (PDF, 49 KB; Updated 7/27/09)
• Decision Tree for Frail Elders with Co-Morbidities (PDF, 25 KB)
• Decision Tree for PD with Co-Morbidities (PDF, 22 KB)
• Decision Tree on Brain Injury and Target Groups (PDF, 27 KB; 10/10/08)
• No Active Treatment (NAT) Algorithm (PDF, 21 KB; Revised 4/26/10 - For Family Care Counties only)
• Login Instructions for Preview of Screener Certification Course (PDF, 215 KB - For course preview only; certification exams not included)
• Assessment/Supplement to the Long Term Care Functional Screen (F-20980) (PDF, 325 KB - For Home and Community-based Waiver Screeners only)
• Listserv Sign Up - Adult Long Term Care Functional Screen
  
  
• 2012 Continuing Skills Testing Video (Adobe Connect, help; 50 minutes)
  This video portrays a functional screen interview in the home of an applicant for long-term care programs. The video is recommended for use for general training purposes.
  
  
• Webcast Trainings (webcast help):
  • Requires Nursing Assessment and Intervention (1 hour, 11 minutes; 3/29/10)
    • PowerPoint Slides (PDF, 58 KB)
  • IADL Section Re-Write (2 hours, 33 minutes; 11/23/09)
    • PowerPoint Slides (PDF, 808 KB)
  • ADL Section Re-Write (1 hour, 43 minutes; 4/14/09)
    • PowerPoint Slides (PDF, 348 KB)
  • Brain Injury (1 hour, 6 minutes; 11/20/08)
    • Brain Injury and the LTC FS in Managed Care (PDF, 51 KB)
    • Decision Tree on Brain Injury and Target Groups (PDF, 26 KB)
  • Behaviors/Mental Health (2 hours, 16 minutes; 7/1/08)
    • PowerPoint Slides (PDF, 195 KB)
  • Archived webcasts (May 2006-May 2008)

Children's LTS Screeners

• Clinical Instructions (Revised 4/16/12)
• Diagnosis Cue Sheet (PDF, 138 KB; Revised 11/16/11)
• Norm-Referenced Assessment Tools for Communication and Learning (PDF, 23 KB; Revised 11/16/11)
• Paper Form F-00367 (PDF, 163 KB; Revised 2/7/11)
• Children's LTS Age-Specific ADL and IADL Questions: 
  • Birth to 6 Months F-00367a (PDF, 20 KB; Revised 2/7/11)
  • 6 to 12 Months F-00367b  (PDF, 24 KB; Revised 2/7/11)
  • 12 to 18 Months F-00367c (PDF, 25 KB; Revised 2/7/11)
  • 18 to 24 Months F-00367d  (PDF, 24 KB; Revised 2/7/11)
  • 24 to 36 Months F-00367e (PDF, 28 KB; Revised 2/7/11)
  • 36 Months to 4 Years F-00367f (PDF, 30 KB; Revised 2/7/11)
  • 4 to 6 Years F-00367g (PDF, 29 KB; Revised 2/7/11)
  • 6 to 9 Years F-00367h (PDF, 32 KB; Revised 2/7/11)
  • 9 to 12 Years F-00367i (PDF, 31 KB; Revised 2/7/11)
  • 12 to 14 Years F-00367j (PDF, 32 KB; Revised 2/7/11)
  • 14 to 18 Years F-00367k (PDF, 32 KB; Revised 2/7/11)
  • 18 Years and up F-00367l (PDF, 34 KB; Revised 2/7/11)

Presentations on Institutional Levels of Care in Children's LTS Programs (Recorded September 2011)

1. Intermediate Care Facility (ICF/MR) Level of Care: Developmental Disabilities (DD LOC) (16 min, 40 sec)
2. Psychiatric Hospital Level of Care: Severe Emotional Disturbance (SED LOC) (38 min, 58 sec)
3. Nursing Home Level of Care: Physical Disabilities (NH LOC) (24 min, 44 sec)
4. Hospital Level of Care: Physical Disabilities (HOS LOC) (13 min, 26 sec)

Mental Health/AODA Screeners

• Clinical Instructions (Revised 5/22/09)
• Paper Form F-00258 (PDF, 77 KB)
  
  

General Resources for All Screeners

• Functional Screen Information Access (FSIA) gateway page

• Functional Screen Application Training 101 

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Last Revised:  April 16, 2012