Module #1: Overview and History of the MH/AODA
1.2 Factors Influencing the Content of the MH/AODA FS
1.3 Screen Development Criteria
1.4 Wisconsin's Other Functional Eligibility Screens
1.5 A Brief History of the MH/AODA FS
Wisconsin's Functional Eligibility Screen for Mental Health and AODA
Services (MH/AODA FS) has been under development since 2001. The MH/AODA
FS is a secure on-line functional needs assessment with programmed logic
to determine eligibility for the following programs:
- Community Support Program (CSP) - Wisconsin's CSPs provide
community-based interdisciplinary social, psychiatric and employment
services to adults with major mental illness.
- Comprehensive Community Services (CCS) - CCS is a new program,
currently in development, which will provide integrated mental health
and substance abuse services to children and adults. CCS has wider
eligibility than CSP, including persons with substance abuse diagnoses
- Community Options Program (COP) - The Community Options Program
Waiver (COP-W) help people get the long-term support they need to
remain in their own homes and communities. Community Options serves
people who need long-term support, regardless of age or type of
disability, who need the same levels of physical or mental health care
as nursing home residents do.
The screen will also automatically refer individuals who have co-morbid
substance abuse issues to a level one screen for UPC (uniform placement
criteria). This UPC tool provides criteria for completing a referral for a
complete AODA assessment at an appropriate level of AODA rehabilitation
and/or treatment level of care. The MH/AODA FS will also refer individuals
with physical health problems and related ADL (activities of daily living)
deficits to a long term care functional screen to determine eligibility
for funding through a home and community- based waiver.
The MH/AODA FS determines eligibility for mental health/AODA programs
for persons age 18 and over. It can be completed for youth age 16 and over
to allow for advanced planning. The MH/AODA FS includes the following:
- Community Living Skills: Vocational, benefits/resource
management, safety, social, financial, home management,
transportation, basic nutrition, general health maintenance, managing
symptoms, grooming, and medication management
- Crises and Symptoms: Hospitalizations, ER visits, crises
interventions, emergency detentions, physical aggression, suicide
attempts, involvement with corrections system
- Risk Factors: Self-injurious behaviors, history of trauma or
abuse, housing instability
- Alcohol or other drug problems and treatment
- Psychiatric diagnoses
- Other diagnoses
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1.2 Factors Influencing the Content of the
The MH/AODA FS is an eligibility screen. It is not a complete
assessment. The content of the MH/AODA FS was determined by several
factors. First of all, it needs to include all of the following eligibility
- The 1996 Wisconsin Blue Ribbon Commission's (BRC) descriptions of
target groups BRC-1 and BRC-2 (either directly or by
"translation" from adjectival language to more objective
- In 1999, DHS 75 administrative rules for AODA rehabilitation and
treatment level of services were promulgated. This rule mandates the
use of either the Wisconsin UPC or ASAS at the point of referral to an
AODA level of service and through out the treatment continuum in
including ongoing treatment planning, change of level of care and
- Admission criteria from the current Wisconsin CSP rule (DHS 63)
(either directly or by "translation" from adjectival
language to more objective functional items); and
- Eligibility criteria from the new statute establishing CCS (either
directly or by "translation" from adjectival language to
more objective functional items).
Second, the MH/AODA FS is needed to gather information on the needs of
people with mental illness. One major barrier to improving mental health
services and systems is the lack of information on the populations served
and their social, psychiatric, and healthcare needs. A good deal of the
information gathered in the functional screen is intended to address gaps
in services and to relate individuals' needs to expenditure data,
to allow for systems redesign and new payment methods in the future.
MH/AODA FS data will be analyzed to see which factors affect service
utilization costs to assist with rate setting in a future managed care
Third, functional screens can help with quality improvement
efforts on several levels.
- MH/AODA FS data will show differences across counties in populations
served or in services provided. For instance, a county can learn that
it has far higher rates of emergency detentions or rep payeeship than
other counties serving people with apparently similar needs.
- MH/AODA FS information can be tracked over time, for each individual
and in aggregate, to see improvements on, for instance, reduced
symptoms and increased independence and employment over time.
- Some items on the functional screen are there purely for advocacy
reasons, i.e., to gather data to promote more help for primary
caregivers, people with post-trauma effects, and people with a mix of
physical disabilities and mental illness and substance abuse.
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1.3 Screen Development Criteria
The following "screen development criteria" were used to
guide screen development:
- Clarity: Definitions and answer choices must be clear to
screeners, the majority of whom are expected to be mental health/AODA
- Objectivity and Reliability: The screen must be as objective
as possible to attain highest possible "inter-rater
reliability" (the likelihood that two screeners would answer the
same way for a given consumer). Subjectivity must be minimized to
ensure fair and proper eligibility determinations. This is
particularly challenging in mental health and substance abuse (as
opposed to physical disabilities), and will be a primary focus of
quality improvement on this initial screen based on screeners' and
consumers' feedback and screen testing.
- Brevity: The functional screen is only an eligibility screen,
not a complete assessment; for efficiency it should be as brief as
- Inclusiveness: Every individual can be accurately screened
with given choices for each question - regardless of adult age,
diagnoses, idiosyncrasies, and co-occurring disorders or other life
- Neutrality: The functional screen should work well regardless
of where the person is living (in a facility, in substitute care,
transitional housing, or at home).
- Service Neutrality: The functional screen should work well
regardless of whether the person is currently receiving any mental
health services or is waiting for needed services.
- Cycle Neutrality: The functional screen should incorporate
the often cyclical nature of mental illness, and not make people
ineligible if they are currently doing well with supports.
The functional screen is "cycle neutral" in the following
- It is not merely a "snapshot" of the present moment, but
an averaging over longer periods, usually several months. (See
section "2.18 Ranking Fluctuating Needs.")
- "Help" includes "support" - supervision,
monitoring, reminding, talking with.
- "Help" includes support and assistance provided by
family and friends as well as paid staff.
- The frequency that help is needed has only minor effects on
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1.4 Wisconsin's Other Functional Eligibility
The functional screen evolved out of Wisconsin's outstanding success
with its long-term care functional screen for frail elders and adults with
physical or cognitive disabilities and a children's functional screen.
Functional eligibility screens have been essential to improving Wisconsin
human service systems. Functional eligibility screens provide all the
- Instantaneous (if done on a laptop), accurate, objective eligibility
- Consistent across all counties, agencies, and individuals
- Eligibilities for multiple programs done all at once rather than in
- Processes for local and state quality oversight and improvement of
eligibility processes and decisions for every applicant.
- Understanding people's needs across systems (physical disabilities,
mental health, substance use, infirmities of aging, developmental
disabilities, health care, social services, residential,
transportation, employment needs).
- Confidential data that can be used for:
- Relating costs to screen information function, including
hospitalizations, to develop a managed-care rate-setting
methodology based on functional screen data.
- Quality improvement of some outcomes over time, for local and
statewide improvement (e.g., people are living where they want
- County and agency-level analyses of population served (or on
- Prioritizing wait lists.
- Recognizing the extent of unpaid supports.
- Quality improvement across counties.
- Identifying gaps between needs and services.
- Advocacy for better funding and systems improvements.
Mental health status is very different from physical disabilities,
infirmities of aging, or developmental disabilities. Mental health factors
are far more difficult to measure "objectively." Mental health
status varies much more over weeks, days, even hours. Most mental health
service needs (thus costs) may relate to intangible factors such as
stress, mood, relationships, specific events, more than to
"objective" factors like demographics, diagnoses, and current
functional status. Most importantly, the functional screen focuses on
needs, i.e., deficits, which seems to violate the principles of
strengths-based, consumer-focused, recovery-oriented models. For all these
reasons, the functional screen has met with less enthusiasm than previous
screens. So why a MH/AODA FS? For these reasons:
- Wisconsin's Long-Term Care Functional Screen (LTC FS) has succeeded
despite initial doubts and cynicism. National experts told us it was
impossible to correlate program costs with functional status; others
have tried and failed for decades. Stakeholders (counties, advocates,
consumers and families) were skeptical. Through a participatory
process of developing and refining the screen over time, stakeholders
came to embrace the LTC FS, which now has had success unprecedented in
the U.S. 80 percent of rates for the Family Care program are based on
functional screen information. Counties and agencies are voluntarily
using the LTC FS to decide rates for services such as residential
settings and day treatment. The LTC FS can assign specific levels of
care and eligibilities more consistently and accurately than
- Mental health system redesign, for which thousands of Wisconsin
stakeholders have worked for years, cannot move forward without more
information on who's being served and what their needs are.
- Many mental health consumers and their families have reported to the
Department that eligibility decisions can vary across counties,
agencies, and individuals. This is a serious problem that must be
corrected, as it is fundamentally unfair to consumers and families.
The MH/AODA FS provides a structured way to look at information to
reduce, as much as possible, variation among screeners. The programmed
eligibility logic represents experts' thinking and yields consistent
- Most mental health consumers who participated in initial testing of
the MH/AODA FS are positive about it, despite the fact that it is
"deficit-based." (One is eligible for services only if one
has a need for those services; hence, functional eligibility
screens are needs-based.)
For these reasons, development of the MH/AODA FS is continuing. Only
time, and everyone's participation, will prove success. The MH/AODA FS
remains a work in progress and users' participation as co-developers is
absolutely critical to that progress.
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1.5 A Brief History of the MH/AODA FS
The MH/AODA FS has been developed by several workgroups since 2001.
- Winter 2001/02 - A small group of DHS staff (social workers and
nurses) developed a preliminary draft screen and eligibility logic
based on BRC criteria.
- Spring '02 - MH Redesign Stakeholders' Screen Workgroup revised
- Summer '02 - Initial screener trainings were done and the screen was
released for the first phase of testing in the four demonstration
- Summer '03 - Inter-rater reliability tests were done.
- Winter '03 - Screen and logics were revised based on above testing
and programmed into an on-line application with entry-level edits and
"instant" eligibility determinations.
- Spring '04 - New screen release, screener trainings, and second
phase of testing.
NOTE: The MH/AODA FS is still being developed! Screen
implementation is an iterative process in which the screen and
instructions are improved over time based on feedback from screeners,
consumers, and other interested parties. On-going quality assurance and
quality improvement processes will need to be established so that the
MH/AODA FS works well for every individual needing services.
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