Contents

• 1.1 History
• 1.2 The LTC FS Determines Eligibility for Long Term Care Programs
• 1.3 Other Functions of the LTC FS
• 1.4 Requirements for Quality Assurance and Screener Qualifications
• 1.5 Screen Quality
• 1.6 The LTC FS Is Voluntary
• 1.7 Confidentiality
• 1.8 Screening and Re-Screening Requirements
• 1.9 The Screening Process
• 1.10 Reliability of Screen and Screeners
• 1.11 Screening Limitations
• 1.12 Strategies to Minimize Screening Limitations
• 1.13 Screening During Acute Episodes
• 1.14 Impending Discharge
• 1.15 Verifying Diagnoses and Health-Related Services

Objectives

By the end of this module you should be able to:

• Recount the process and major criteria used to develop the LTC FS.
• Explain what the LTC FS is designed to do.
• Explain how the LTC FS is to be administered, by whom, and in what manner.
• Utilize strategies for minimizing identified Screen limitations.
• Accurately document fluctuations in peoples abilities and long term care needs.
• Recognize when the services of a medical professional are needed to properly complete the health related sections of the LTC FS.

1.1 History

The Wisconsin Long Term Care Functional Screen (LTC FS) has been under development since 1997. It is a functional needs assessment describing assistance needed with:

• Activities of Daily Living (ADL's-bathing, dressing, mobility, transfers, eating, toileting)
• Instrumental Activities of Daily Living (IADL's-meal preparation, medication management, money management, telephone, transportation, and employment)
• Health Related Tasks (including skilled nursing)
• Diagnoses
• Behavioral Symptoms and Cognition

The LTC FS also includes information on risk factors, mental health and substance use, and where the person would like to live.

The LTC FS computer application has complex logics programmed into it that interpret entered data to determine applicant's nursing home level of care, disability level of care, and functional eligibility level for Wisconsin's long term support programs. Family Care pilot counties have been using the LTC FS since 1998. Use of the LTC FS was expanded to Partnership and PACE programs in November of 2001, and is being expanded to other home and community-based waiver programs throughout Wisconsin.

The LTC Functional Screen's eligibility and nursing home level of care logics have been tested for reliability and validity, and approved by the Centers for Medicare and Medicaid Services  to replace previous methods of home and community-based waiver eligibility in Wisconsin. The major advantages of the LTC FS are that eligibility determinations are instantaneous upon completion of the LTC FS and reflect an objective method of eligibility determinations.

The WI LTC FS was developed through four workgroups which included county case managers experienced in LTC eligibility and assessments. The primary screen development workgroup reviewed numerous other screens and assessment such as the Minimum Data Set (MDS) that nursing homes must complete, and the OASIS form that home health agencies must complete.

The WI LTC FS is different from those forms because it had to meet the needs of Wisconsin's LTC redesign effort. In particular, the LTC FS needed to work for all three target groups: frail elders with health conditions or dementia (mild or severe); younger people with physical disabilities, some of whom have no health problems; and people with developmental disabilities with various cognitive functioning levels, behavior symptoms, and/or health problems. The WI LTC FS needed to work to describe people living at home or in substitute care settings (group homes, adult family homes) or in institutions (nursing homes, ICF-MRs). Other criteria used to develop the WI LTC FS include the following:

• Clarity--Definitions and answer choices must be clear to screeners (most of whom are not nurses)
• Objectivity and Reliability--The LTC FS must be as objective as possible to attain highest possible "inter-rater reliability"-i.e., that two screeners would answer the same way for a given consumer. Subjectivity must be minimized to ensure fair and proper eligibility determinations.
• Brevity--The LTC FS is only a "needs assessment" to determine program eligibility. It serves as a baseline for more in-depth assessment to develop a service plan that reflects the consumer's strengths, values, and preferences.
• Inclusiveness--Every individual can be accurately described with given choices for each question--for elders, people with dementia, physical disabilities, or developmental disabilities, healthy or not.

Note: For HCBW counties a full assessment and service plan packet must be completed per waiver manuals prior to implementation of the waiver.

1.2 The LTC FS Determines Eligibility for Long Term Care Programs

For people age 18 or older, the LTC FS determines functional eligibility for HCBW programs. Wisconsin has five waiver programs for persons who are a frail elder, have a physical disability, or have a developmental disability. These waivers are COP, CIP II, IRIS, Family Care and PACE/Partnership programs.

Once an applicant's LTC FS is complete, the eligibility logic built into the application is able to determine that person's Nursing Home Level of Care (NH LOC), Developmental Disability Level of Care (DD LOC), and Family Care Level of eligibility (Family Care Nursing Home LOC and Family Care Non-Nursing Home LOC) as well as eligibility for the other waiver programs. NH Level of Care or DD Level of Care is absolutely necessary to be eligible for COP/W, CIP II, IRIS, PACE/Partnership because those programs can only serve NH eligible people.

Wisconsin has the following four nursing home levels of care:

1. Intermediate Care Facility, Level 2 (ICF-2)-lowest needs
2. ICF Level 1(ICF-1)-moderate needs
3. Skilled Nursing Facility (SNF)-high needs
4. Intensive Skilled Nursing (ISN)-highest needs

Wisconsin has five waiver programs for people with developmental disabilities. They are CIP 1A, CIP 1B, IRIS,  Family Care and PACE/Partnership.

Wisconsin has four institutional levels of care for people with developmental disabilities:

1. DD1A-DD person with significant medical problems
2. DD1B-DD person with significant behavioral problems
3. DD2-DD person not DD1a or DD1B who needs help with all or most activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
4. DD3-DD person who is more independent with most ADLs and IADLs

Note: Individuals with developmental disabilities who meet certain criteria for no active treatment (NAT) may be placed on a physical disabilities or frail elderly waiver program (see 10.10 No Active Treatment).

For Family Care there are two levels of eligibility:

1. Family Care Nursing Home Level of Care
2. Family Care Non-Nursing Home Level of Care

Level of Care in Home and Community-Based Waiver Programs:
In general, Wisconsin's federally approved home and community-based long-term care programs require that the applicant achieve a qualifying nursing home (NH) or developmental disability (DD) level of care on the Long Term Care Functional Screen as described above. People who do not meet a qualifying level of care on the Functional Screen may still be eligible for COP Level 3 or for a more limited Family Care benefit.

In addition to meeting level of care, the applicant must meet related non-financial eligibility criteria. The applicant must meet residency requirements and his/her physical or medical condition must be expected to last more than one year or result in death within one year and, for applicants who are less than 65 years of age, a disability determination is required.

It is important to remember that level of care and non-financial program criteria do interact as eligibility is determined. For example, applicants who have shorter-term needs (90 days or longer) may still receive a nursing home level of care. However, they will not be eligible for the CIP 1A/1B, CIP II, COP-Waiver, PACE, Partnership and the Family Care home and community-based waiver programs because they have not met the requirement that the physical/medical condition last one year or longer. These applicants may be eligible for reduced benefits under the Family Care program.

The remainder of this section describes NH and DD LOC and how these interact with Family Care eligibility.

NH or DD Level of Care and Family Care:
NH or DD level of care is very important in Family Care as well.

To qualify for NH or DD level of care, a person must have a long-term care condition likely to last more than one year. 

Screeners must understand the ways in which NH and DD levels of care interact with the two levels of Family Care eligibility. The two levels of Family Care eligibility are "Family Care Nursing Home LOC" and "Family Care Non-Nursing Home LOC." (A third level would be "Not Eligible for Family Care").

Family Care Nursing Home LOC: Family Care Nursing Home LOC level includes all NH eligible people. If someone receives a NH or DD level of care, they are eligible at the Family Care Nursing Home LOC.

Family Care Non-Nursing Home LOC: People at the Family Care Non-Nursing Home LOC level usually need help with only one or a few particular ADLs or IADLs and do not have a nursing home LOC or DD LOC. Only those people at the Family Care Non-Nursing Home LOC who have a Medicaid card are entitled to the program.

People at the Non-Nursing Home LOC not eligible for Family Care should be helped by the Resource Center with options counseling.

Screeners should always confirm that the NH or DD level of care seems appropriate for the person. If it seems someone should be nursing home eligible, then the LTC FS should assign them a NH level of care. Be sure you confirm all health-related services with a nurse or other health professional familiar with the consumer. Consult with your Screen Liaison, who can contact the Department if necessary.

1.3 Other Functions of the LTC FS

1. Serve as a foundation for the comprehensive assessment done by the long term care program selected by the consumer.
2. Provide data for quality assurance and improvement studies for the Department and long term care programs utilizing the LTC FS, including identifying cases for targeted reviews.
3. Identify whether an applicant is currently in need of Adult Protective Services (this factor affects entitlement for persons at Family Care Non-Nursing Home LOC).
4. Indicate the need for referrals to Adult Protective Services, mental health services, substance use services, or other community resources.

For Family Care Counties, the LTC FS also:

1. Provides a framework for information-gathering during Pre-Admission Counseling.
2. Is used to set monthly payment rates based on people's functional needs.
3. Documents factors to aid in prioritizing waiting lists.

1.4 Requirements for Quality Assurance and Screener Qualifications

As discussed above, the Wisconsin Long Term Care Functional Screen (LTC FS) determines a person's eligibility for Wisconsin's long term support programs, including Family Care, PACE/Partnership, and the home and community-based waiver programs. Family Care is an entitlement, so for Family Care counties, the screen determines entitlement to services. Because the LTC FS determines program eligibility, special requirements for quality assurance and screener qualifications are necessary.

Screener Qualifications

All persons administering the functional screen must meet the following four conditions:

1. Meet the following minimum criteria for education and experience:
   • Bachelor of Arts or Science degree, preferably in a health or human services related field, and at least one year of experience working with at least one of the target populations; or
   • Prior approval from the Department based on a combination of post-secondary education and experience or on a written plan for formal and on-the-job training to develop the required expertise prepared by the agency
   • In HCBW counties, people screening DD individuals must be qualified as QMRPs**.
2. Meet all training requirements as specified by the Department
   • Completion of the web-based clinical certification course is currently the primary way to meet the Department's training requirements. In specific, all screeners should read screen instructions in their entirety.
3. Have experience working with long term care consumers
4. Pass all Screener Certification exams after receiving training. There are eight certification tests that are part of the online course. All eight must be successfully completed (a score of 80% or better) to become a certified LTC FS Screener

Further, for Family Care, Resource Center and MCO managers and screen liaisons must:

1. Family Care providers should also see the Resource Center and MCO contract for quality assurance requirements.

**"Qualified Mental Retardation Professional" or QMRP means a person who has specialized training in mental retardation or at least one year of experience treating or working with persons with mental retardation and is one of the following:

1. A Psychologist licensed under ch. 455, stats
2. A Physician
3. A Social Worker with a bachelor's degree or graduate degree from a school of social accredited or approved by the council on Social Work Education.
4. A Physical or Occupational Therapist who meets the requirements of s.HSS 105.27 or 105.28
5. A Speech Pathologist or Audiologist who meets the requirements of s.HSS 105.30 or 105.31
6. A Registered Nurse
7. A Therapeutic Recreation Specialist who is a graduate of an accredited program who has a bachelor's degree in a specialty area such as art, dance, music, physical education, or recreation therapy; OR
8. Human Service Professional who has a bachelor's degree in a human services field other than those noted under 1-7, such as rehabilitation counseling, special education, or sociology.

1.5 Screen Quality

Parallel to the screener qualification, training, and certification requirements stated above, there are quality performance and assurance requirements to ensure consistency and accuracy of administration of the screen. There are three levels of functional screen quality assurance.

1. The first efforts are quality assurance beginning with the screener. It is the screener's responsibility to be objective in screening, to be informed of the instructions, and to corroborate information gathered from the consumer. Questions that arise can be addressed by the person in your office designated as Screen Liaison.
   
2. Among the Screen Liaison's roles is to oversee quality assurance. The methods each agency will be conducting will, at a minimum, include:
   • Inter-rate reliability testing;
   • Training, mentoring, and monitoring new screeners;
   • Random sampling for accuracy and consistency;
   • Completing reports; and
   • Consulting with state staff on consumers.

For the Family Care Program, the final step in quality assurance occurs at the State. Staff at the Department will review screens and quality assurance methods during annual site visits and quarterly examine a series of analyses and comparisons of all agencies' screens. Each agency will receive a report following such reviews and request the agency to correct and amend screens done in error.

1.6 The LTC FS Is Voluntary

Consumers must consent to having the LTC FS completed in order to enroll in a long term care program (COP, CIP, IRIS, Family Care, or PACE/Partnership). The person being screened should consent to completion of the LTC FS and its submission to the Department for aggregate data research. No screen should be completed without the person's consent.

Screening agencies shall comply with confidentiality rules and requirements and shall obtain a signed release of information from the person or the person's guardian or power of attorney, where applicable, for the use of medical records, educational records and other records as appropriate before conducting the LTC Functional Screen. Signed releases of information shall be included in the person's records when appropriate.

1.7 Confidentiality

Any information collected for the screen or during the screening process is confidential. It is to be treated with the same requirements for confidentiality as other long-standing screens and assessments. If a person enrolls in a long term care program, the functional screen can be shared with that program without separate written permission.

1.8 Screening and Re-Screening Requirements

In the home and community-based waiver programs and the PACE/Partnership programs an initial screen is required to establish eligibility prior to receiving services. An annual screen is required thereafter to ensure continued functional eligibility.

In Family Care:
County Resource Centers will be the most common place from which long term care consumers can be screened by the LTC FS to determine their functional eligibility for LTC programs. It should be noted however, that Resource Centers do more than just administering the LTC FS, they are also places where long term care consumers and their families can go for counseling on all long term care options. Resource Centers are responsible for information and assistance, early intervention and prevention, and informing the public about community resources both within the LTC system and beyond it. The multifaceted nature of Resource Centers is beneficial to consumers, since they are able to get information on all long term care through a single entry point.

In addition to Resource Centers, the LTC FS may be administered by Family Care--Managed Care Organizations (MCOs) during "re-screening", or other long term care programs that manage their own eligibility and enrollment processes. MCOs should not be involved with doing someone’s screen prior to enrollment.

It is critical that whenever the condition of a person enrolled in a LTC program substantially changes, the LTC FS should be updated and the eligibility logic re-run to determine if the change in condition impacts their NH/DD level of care or Family Care Nursing Home LOC or Family Care Non-Nursing Home LOC eligibility.

Examples when a re-screen is necessary:

• Larry, an 88-year-old Family Care participant suffers a stroke.
• Mary, a 79-year-old woman regains her mobility after healing from a hip fracture.
• Jose, a 44-year-old man with Downs Syndrome is diagnosed with early on-set dementia.

It is important that when re-screens are done, that the screener review the person's previously completed screens for information and historical perspective. The LTC FS can be done more often than yearly if someone requests it.

1.9 The Screening Process

The screening process requires face-to face contact with the individual being screened.
No screen should be completed without a meeting with the consumer, even if s/he is unable to communicate.

The Interview Process

The LTC FS was not designed as an interview tool; screeners are expected to use their professional skills to adjust their interview style to the individual and the situation. The screen can be done in any order.

The face-to-face interview can take place in any setting, from the consumer's residence, to a substitute care setting such as a CBRF, to a hospital or nursing home. It may take more than one contact with the consumer to complete the screen.

Screeners should use their professional interviewing skills to gather information in a way that is appropriate for a given consumer. The screener will need to ask questions in a variety of ways, be familiar with the participant target group being interviewed, and use collateral informants as necessary. Collateral informants include family, significant others, formal or informal caregivers, health care providers, and agencies serving the consumer. The screener must always have a face-to-face contact with the consumer, even if other informants are used.

Sometimes answering the Target Group question requires using the same information gathered later within the LTC FS. This is because the statutory definitions of the target groups require significant functional impairments in several areas of living, including ADLs, IADLs, cognition, behavior, etc. Again, screeners are to use professional interviewing skills to determine the person's needs and abilities. In doing so, you will sometimes be answering the Target Group and the ADL/IADL questions at the same time. Follow all instructions and Target Group guidelines closely.

1.10 Reliability of Screen and Screeners

This screen has been repeatedly revised with users' input and statistically proven to have acceptable levels of validity and reliability. However, it is generally recognized that any objective rating of consumers' functioning, cognition, behavior, and symptoms can be difficult. The difficulty calls for extra vigilance to ensure the greatest possible accuracy in the LTC FS. This is why screeners must be certified and why the Department and Wisconsin long term care programs must have ongoing quality assurance processes.

Screeners should adhere to the following guidelines:

• Read and follow screen definitions and instructions closely
• Go slowly and carefully enough to be accurate even with someone you know well
• Do not "inflate" any answers because you think a consumer has special costs not "visible" through the screen. Instead, you should always select the answer that most accurately describes the consumer's status
• All screening agencies should have experienced LTC FS Screeners to assist you with questions. Refer all questions to your designated Screen Liaison Staff. The Screen Liaison in turn will refer unresolved questions to the Department as necessary. In this way, interpretations can be kept consistent and communicated to all programs utilizing the LTC FS, and revisions can be made to the LTC FS if necessary.

An applicant's LTC FS will be taken in total. The LTC FS logic has been programmed to "weigh" all clinical factors in ways that reflect likely needs. The Risk section of the LTC FS plays an important role in how a consumer's screen works in total. The Risk section was specifically developed to be able to "capture" people who might be independent in ADLs and IADLs, without any cognitive impairment-but still at risk. So screeners should never "inflate" their answers in other modules to compensate for risk factors; screeners can document risk factors in the Risk section of the LTC FS.

1.11 Screening Limitations

In particular, screeners should be aware of the following limitations found in national studies to be characteristic of all similar screens:

1. Health care and institutional providers tend to overrate the consumer's dependency on others.
2. Guardians, spouses, and family members often tend to overrate the consumer's dependency on others.
3. Consumers often underrate their need for help from others and exaggerate their abilities.
4. Consumers' functional abilities can fluctuate, making it difficult to select a "best" answer.
5. Consumers can provide conflicting information at different times or to different screeners.
6. Screen answers vary somewhat depending on whether the screener knows the consumer well or not.
7. Screen answers vary somewhat depending on the profession of the screener.
8. While objectivity is the ultimate goal, some subjectivity may remain in some questions.

1.12 Strategies to Minimize Screening Limitations

A and B: Conflicting Information from Different People

Sometimes screeners will get different information from different sources. Consumers may function less independently in day care facilities or institutions than they do at home, and staff at such facilities may tend to perceive more dependency than family or peers in the community might perceive. Screeners are to use their best professional judgment to describe the person's functional abilities as accurately as possible given all the information from multiple sources. Keeping in mind the tendencies noted above, the best source of information (besides the person themselves) is someone who does a lot of direct care for the person and likes her/him. In a health care facility, the screener should (if collaboration is needed) talk to a nurses' aide, not just the nurses. In the home, a personal care worker might provide a more accurate description than family members.

C: Consumer Gives Apparently Inaccurate Information

Sometimes the consumer's statements about her/his abilities do not seem to cohere with reality. If you feel this is happening, follow this three-step process:

1. Seek more details
2. Seek collateral informants, other people you could ask for additional information
3. Use your professional judgment to select what seems to be the most accurate answers. Follow the definitions and instructions for the screen

Remember that the goal is to be as objective as possible, to have high "inter-rater reliability"-meaning that other screeners would choose the same answer you did. That is why your professional judgment must be based on as much objective information as possible. Objective information can be obtained by asking questions, asking for demonstrations, observing evidence carefully. If the proper answer is still not clear, discuss it with your Screen Liaison, who can then, if necessary, ask the Department for guidance.

So, for example, if someone tells you he bathes himself, but he has obviously poor hygiene and he can barely walk and transfer himself, you should follow the three steps above:

1. Seek more details: Ask him how he bathes (bath? shower? sponge bath?). Ask if you can look at his bathroom to check for accessibility and adaptive equipment. Ask him how he gets in and out of his bathtub. If it has high sides, ask him if he can lift his foot that high, and to show you.
2. Seek collateral informants: Ask him if you can talk with his family members. They may have opinions ("He should be in a nursing home") as well as objective information ("He's really gone downhill since mom died last year, he's fallen at least four times, he can barely move, he hasn't been in that bathtub for months, he won't accept any help from us even when we tell him he needs a bath.")
3. Use your professional judgment to select the best answer: In this example, it seems he's definitely not independent with bathing. It's not exactly clear whether Bathing Level of Help #1 (helper does not have to be present throughout task) or # 2 (helper does have to be present throughout task) is most accurate. With the history of recent falls and his excessive independence, #2 might more accurately reflect what he really needs at this time.

D. Abilities Fluctuate

Some similar screens or data collection instruments like the Minimum Data Set (MDS) required of nursing homes and the OASIS (required of home health agencies) were designed to provide a "snapshot" view of functional status. So their questions ask, for example, for functioning in the past seven days, or over the past month. The LTC FS provides a broader view to more accurately reflect an individual's likely long-term care needs. We realize that many long-term care consumers have conditions and abilities that fluctuate over time, and that it is sometimes difficult to choose the best "multiple choice" answer. In completing the screen, please follow the following guidelines:

• If the person's functional abilities vary over months or years, select the answer that seems closest to the average frequency of help needed.
• If the person's functional abilities vary day to day, select the answer that most accurately describes their needs on a "bad" day.
• If the person's functional abilities vary week to week, try to select answers that reflect how you would staff them if you had to.

1.13 Screening During Acute Episodes

An acute episode involves conditions which are expected to resolve in the next few weeks. These types of episodes can occur at home, in the hospital, in a nursing home, or in other locations.

The LTC FS may be completed when consumers enter nursing homes and residential facilities. Approximately 70% of people enter nursing homes from hospitals. It is expected, then, that some LTC FS will reflect higher needs due to more acute conditions and that many people may improve over the next several days, weeks, or months. Their improvement will be evident in their next LTC FS. However, if a person experiences a change in condition likely to affect their eligibility, an "02-Rescreen" should be done. 

For Family Care, the LTC FS must be completed by the Resource Center as part of pre-admission counseling when consumers enter nursing homes and residential facilities.

1.14 Impending Discharge

When doing the LTC FS on someone preparing for discharge from a skilled health care facility, complete the screen based on how the person would function at home when they go home. This looking ahead is a normal part of discharge planning. So, if, for example, oxygen and intravenous (IV) will be stopped before person goes home in two days, do not mark them on the screen. If family is learning to do a 2-person pivot transfer to prepare to use at home, mark that on the screen, even if now the hospital does one-person transfers with a mechanical lift. It will take additional time and talking with facility staff, family, etc., to get the most accurate picture of the person's needs at home, after discharge.

The screener must be able to envision the person at home. This is why screeners must have experience in community care for the target group being screened.

1.15 Verifying Diagnoses and Health-Related Services

The Health-Related Services table of the LTC FS is extremely important to determining a person's eligibility. The table collects objective data used by the programmed logic to determine whether the person meets nursing home or DD level of care. This in turn determines eligibility for home and community-based waivers and affects the Family Care eligibility (Nursing Home LOC or Non-Nursing Home LOC). Accuracy in this information will be a focus in quality assurance and improvement efforts both locally and at the Department. The diagnoses will provide important data for evaluating Family Care and other long term care programs, but do not have direct role in the eligibility logics. The target group question (discussed in module 2) may require help from health care professionals as well.

No health care providers' signatures are required on the screen, but screeners must take the time to verify health-related information. Screeners will need to verify diagnoses and health-related services for the LTC FS, and can verify information needed for the target group question at the same time. Explain this to the person, and either get permission to contact their physician's office or help arrange an appointment.

***In almost all cases, screeners will need to contact a health care provider to get accurate information on health-related services, diagnoses, and, if necessary, the target group question.***

Last Revised: August 08, 2012
Wisconsin Department of Health Services
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