CLTS FS Instructions Module #3: Diagnoses

Contents

3.1 Has the child been determined disabled by the Disability Determination Bureau (DDB) or by a Social Security Administration?
3.2 Transplant Information
3.3 Whose Diagnosis Accepted?
3.4 Child's Diagnoses Must be Current
3.5 Required Documentation of Mental Health Diagnoses
3.6 Other Diagnostic Considerations
3.7 Diagnoses Cue Sheet
3.8 Is this a PRESENTING Diagnosis? 
3.9 Primary Care Physician Information


3.1 Has the child been determined disabled by the Disability Determination Bureau (DDB) or by a Social Security Administration?

Check "Yes" if, within the past 12 months, the child was in the Katie Beckett Program in Wisconsin, was receiving Supplementary Security Income (SSI) or Social Security related to the child's disability, in any state, or on a Wisconsin state funded CLTS Waiver. This can be checked "yes" based on parent report.

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3.2 Transplant Information

If child has had a transplant, indicate the date completed. If pending one, check the appropriate box. When a parent reports that a child is pending a transplant, the transplant must be imminent in the next 12 months. One way of measuring that is to find out if the child is on the United Network of Organ Sharing (UNOS) list. This does not exclude children who are having autologous (out of self) transplants or have a previously designated donor. However, the list is one useful measure of imminence. A specific plan or timeline for the transplant is another option to establish this criterion. Do not check Pending Transplant if a child may need a transplant following a specific event or for a child who will eventually require a transplant but the time frame is unknown.

List all pending as well as previous transplants that are accurate at the time of the home visit.

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3.3 Whose Diagnosis is Accepted?

Screeners are not to interpret people's complaints or symptoms. If parents report a diagnosis (other than Mental Health Diagnoses - see below), the screener must find out when the diagnosis was made and who diagnosed the child. If a parent can report that a physician diagnosed the child, the screener can check the diagnosis box. The point is to try to separate the parent's opinion or suspicion, which shouldn't be checked for diagnoses, from parent's report of diagnoses that were made by doctors.

  • School records and Birth-to-3 records do not count for diagnoses unless the records state that the diagnoses were made by properly qualified professionals e.g., MD or psychologist. The exception to this is that Birth-to-3 Program professionals are qualified to make the diagnosis of "Developmental Delay" only.

  • A teacher, social worker or therapist diagnosis or suspicion of a specific diagnosis does not count for diagnoses for the purposes of the CLTS FS. Even if school personnel have done an Autism rating scale, or the child is qualified for special education services within the Autism category, the screener will not check the diagnosis of Autism on the screen.

  • Only check the diagnoses that have been reported to the screener or that the screener sees listed within appropriate documentation. Do not interpret diagnoses from symptoms. For example, if a child has multiple delays in a variety of areas such as learning, mobility, and self care, do not assume they have a diagnosis of Developmental Delays. Only check the diagnoses for which the screener has verbal report or written record of.

If the screener suspects that a parent is over stating a child's disability, the screener will want to confirm the diagnosis with a qualified professional.

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3.4 Child's Diagnoses Must Be Current

Accept any medical/professional diagnosis made within the past year. If a diagnosis was made more than a year ago, confirm that the diagnosis is still accurate for that child and is relevant to the child's needs or condition. If this is the case, then the diagnosis may be entered on the screen even if it was made greater than one year in the past.

There are a few diagnoses on the table that are conditions that may improve. Cancer, a wound or burn, failure to thrive, even some mental health diagnoses, are examples of conditions that might not really apply to a child any more. If a condition has improved such that the child is not on any medications or treatments related to the diagnosis, and no longer has any symptoms from it, then that diagnosis should not be checked on the Diagnoses table.

Example A: Ricky is a 15-year-old boy with Muscular Dystrophy. When he was 6 he was successfully treated for Leukemia. He has had no recurrence or symptoms related to Leukemia since then. The screener would not check Cancer on the diagnosis table.

Example B: Sophia is a 5-year-old girl who is doing well and is typical size, weight, and development for her age. As an infant, she was diagnosed with Failure to Thrive, but that was resolved by the time she was 3 years old. A screener would not check Failure to Thrive on the Diagnosis table.

If a screener is not certain if a diagnosis is still considered current for the child, the screener will need to check with the family or qualified medical professionals.

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3.5 Required Documentation of Mental Health Diagnoses

Any diagnosis of a mental health condition, which includes Autism and Autism Spectrum Disorders (such as Asperger Syndrome and Pervasive Developmental Disorder), Substance Abuse, and all other Mental Health Diagnoses require the screener to see written documentation or have verbal confirmation of that diagnosis from a qualified professional (Psychiatrist or Clinical Psychologist). Diagnoses of developmental or physical conditions can be accepted without documentation if the parent can recall when the diagnosis was made and which qualified professional made the diagnosis.

In order to check a Mental Health Diagnosis on the Diagnosis Page, certified screeners must remember to verify the following:

  • That a specific mental health diagnosis (NOT a clinical impression or possible diagnosis) was made by a Psychiatrist, Psychologist, Physician, Licensed Clinical Social Worker or Licensed Professional Counselor for whom diagnosing a mental health disorder is appropriate to their specialization and within the scope of their training and practice, AND

  • The diagnosis was made through a process using standardized testing, another norm-referenced tool, or through a thorough professional assessment of the child's symptoms.

This verification can be made through written medical record documentation or verbal exchange as long as all requirements are met. This can be accomplished by reviewing clinical assessments or mental health evaluations completed at the time of diagnosis that include not only the diagnosis but also a description of the presenting symptomatology. Recent or current progress notes may also be used that detail the symptoms associated with the verified diagnosis, indicate the symptoms persists, and states the treatment protocols being used to address the symptoms.

Screeners must include information in the note section to support the verification of all mental health diagnoses. In subsequent screens, screeners must be certain the mental health diagnosis and symptoms are still accurate for the child but do not need to verify the diagnosis with the qualified professional on an annual basis.

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3.6 Other Diagnostic Considerations

AVOID SYNONYMS FOR CURRENT CONDITIONS
If a child has a condition captured by one of the diagnoses listed on the screen or on the diagnosis cue sheet, check that one diagnosis. Do not include diagnoses that describe another diagnosis already checked for that child's condition.

Example A: If a child has "Down syndrome," the screener checks that box. The screener does not have to also check synonyms such as "cognitive disability," "developmental disability," and "genetic/chromosomal disorder."

Example B: If a child has a current diagnosis of Cognitive Disability with a previous diagnosis of Developmental Delays from over a year ago, check only Cognitive Disability on the screen.

If the screener is not certain that one diagnosis is inherent in another diagnosis, then check both as long as they are considered current diagnoses.

MULTIPLE CONDITIONS/DIAGNOSES
A child may have more than one condition - e.g., Cerebral Palsy and Cancer. In those instances, both Cerebral Palsy and Cancer should be checked. The CLTS FS should accurately capture each current diagnosis given to the child. CLTS FS quality assurance procedures will determine if the diagnoses listed for a child are compatible with the needs and supports the child receives.

Example A: The screener screens a child with Muscular Dystrophy and the screener also checks, in the health-related services section, that the child is getting IV's. A second diagnosis should be present to explain why the child is getting IVs.

Sometimes a child may have a primary diagnosis as well as secondary diagnoses, again, check all current diagnoses. If the screener thinks the primary diagnosis captures the functional limitations that the child has, it is still important to list each diagnoses given to a child.

Example B: The screener meets a boy who has a diagnosis of Cognitive Disability and also has Asthma and Allergies. The functional limitations he experiences are directly related to his diagnosis of Cognitive Disability. Nevertheless, the screener would check all three diagnoses on the Diagnoses Page.

PENDING DIAGNOSES
In many instances, physicians cannot officially diagnose a child until s/he gets older. In those cases, other Functional Screen questions can determine correct program functional eligibility for the child, and the absence of a diagnosis should not matter. Provisional diagnoses can not be selected on the CLTS FS.

DOWN SYNDROME
There are two listings for Down Syndrome on the Diagnoses Page. One is for Down Syndrome - Mosaic or Translocation and the other is Down Syndrome - Trisomy 21. Generally parents will know which kind of Down Syndrome their child has. Trisomy 21 is the traditional and most common form (95%) of Down Syndrome. In Trisomy 21, the child has an extra chromosome 21 in all cells of their body. Mosaic Down Syndrome indicates that the child has the extra chromosome 21 in some but not all of their cells. Because not all cells contain an extra chromosome 21 the range of physical problems varies depending on the ratio of cells with 46 chromosomes to those with 47 chromosomes. Down Syndrome caused by a translocation of a part of chromosome 21 attaching to another chromosome also varies in severity.

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3.7 Diagnoses Cue Sheet

The diagnoses table on the CLTS FS is not all-inclusive; only some of the more common diagnoses or diagnostic categories are listed. Different diagnoses that have a similar meaning are clustered together. For brevity, this table includes the most common and the most "important" diagnoses the screener will encounter. "Important" diagnoses for the Functional Screen means those that are specifically mentioned in state or federal eligibility requirements and others that are needed to establish a specific target group. Some of the diagnoses on the table are required for a child to be eligible. Therefore, accurate diagnoses are very important for the CLTS FS.

The screener will sometimes encounter diagnoses that the screener does not see listed in the table. If the screener does not see a particular diagnosis listed on the table or is uncertain which diagnoses are considered similar, the Diagnoses Cue Sheet (PDF) will help to guide the screener's response. The Diagnosis Cue Sheet is accessible via a web-link from the Diagnosis page of the CLTS FS. The Cue Sheet will indicate which box to check on the Functional Screen Diagnosis Table. If the diagnosis is not on the cue sheet, then the screener can check "Mental Health - Other" or "Substance Abuse - Other" box, if appropriate, and write it in. For non-Mental Health or Substance Abuse conditions, enter the diagnosis in the note section on that page. Screeners' entries will be reviewed periodically to update the Cue Sheet.

If you use the Diagnosis Cue Sheet to determine the proper box to check on the Diagnosis page, write the specific diagnosis the child has in the note section at the bottom of the Diagnosis page.

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3.8 Is this a PRESENTING Diagnosis?

For every Diagnosis checked on the CLTS FS, the screener must indicate if it is a PRESENTING Diagnosis. Is the diagnosis checked suspected to be a primary cause for the child to seek long term support services? Presenting diagnoses are those which focus our efforts. A presenting diagnosis (diagnoses) resulted in the child having needs now, or expected to have needs, that can be addressed through long term support services and will become the direct focus in a service plan for this child. The needs the child has, directly related to their presenting diagnosis (diagnoses) is why a CLTS FS is being completed on behalf of this child.

Example A:
A child has needs related to their diagnosis of Pervasive Developmental Disorder that can be addressed through long term support services, specifically waiver services. The child also has a diagnosis of asthma and/or allergies and/or a facial tic and/or a clef lip. The PRESENTING Diagnosis for this child is Pervasive Developmental Disorder. The other diagnoses are still indicated on the Diagnosis page but they are not PRESENTING Diagnoses.

Example B:
A child is applying for long term support services through the Family Support Program because they have home modifications needed for their physical limitations related to a diagnosis of Cerebral Palsy. This child also needs support services due to a Cognitive Disability. In addition, the child has reflux and/or a bedsore and/or delayed puberty and/or hearing loss and/or a neurogenic bladder. The PRESENTING Diagnosis for this child is Cerebral Palsy and Cognitive Disability. The other diagnoses are still indicated on the Diagnosis page but they are not PRESENTING Diagnoses.

Example C:
A child has Down Syndrome and is applying to a variety of sources for long term support services to help with needs related to their condition. They also have been diagnosed with an ulcer and/or eczema and/or a soft palate deformity and/or torticollis. The PRESENTING Diagnosis for this child is Down Syndrome. The other diagnoses are still indicated on the Diagnosis page but they are not PRESENTING Diagnoses.

Example D:
A child has severe food allergies resulting in needing a g-tube and needs help with the medical costs associated with this diagnosis. They are applying for long term support services through the Katie Beckett Program due to these allergies. The child also has diagnoses of ADHD and/or low muscle tone and/or a hip dislocation and/or an expressive language disorder. The PRESENTING Diagnosis for this child is Allergy. The other diagnoses are still indicated on the Diagnosis page but they are not PRESENTING Diagnoses.

All diagnoses a child has are relevant on the CLTS FS. By indicating which diagnoses are "presenting diagnoses" the screen is able to better differentiate the primary concerns a child has that brought them to the point of applying for long term support services. It is expected that a child would have no more than three "presenting diagnoses."

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3.9 Primary Care Physician Information

This is a required field. The information does not affect functional eligibility. It may eventually be used for state and local systems changes to improve children's access to primary health care. These data are also required for federal outcome measurements.

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Last Revised: April 29, 2014
Wisconsin Department of Health Services
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