MH/AODA Functional Screener Instructions
Glossary of Acronyms (PDF, 75 KB)
Module #2: The Screening Process and Quality Assurance
Screens may only be done with consumers by a mental health/AODA practitioner who has met DHS qualifications and training requirements. Screeners must be direct or contracted employees of county agencies specified by DHS as screening pilot agencies.
The MH/AODA FS needs to be completed by MH/AODA practitioners, not consumers themselves, in order to obtain federal approval of its use. We agree that this is not as consumer-focused as we'd like, and in fact adds a significant risk of practitioners' subjectivity to the screen. Instructions, trainings and quality assurance processes (including close communication between screeners and state staff) will reduce subjectivity enough to ensure reliable and valid results.
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 they have communication difficulties.
The face-to-face interview can take place in any setting (e.g., the applicant's residence, a group home, day services center, a hospital or a restaurant). It may take more than one contact with the consumer to complete the screen.
The MH/AODA FS is NOT an interview tool; do not just go through it like a checklist with someone. The screen can be done in any order. More importantly, it should be done within a larger conversation about the whole person, not just their needs.
Screeners should use their best interviewing skills to gather information in a way that is appropriate for a given consumer. The screener should ask questions in a variety of ways, and use collateral informants as necessary. Collateral informants include family, significant others, formal or informal caregivers, health care providers, and agencies serving the consumer. A release of information must be signed by the consumer to access collateral information (either written or verbal). The screener must always have a face-to-face contact with the consumer, even if other informants are used.
The MH/AODA FS is based on the person's diagnoses, symptoms, and need for help from others (i.e., functional impairments). Such a deficits-based approach to mental health service delivery and practice is fundamentally contrary to recovery-oriented practice. That said, program eligibilities (particularly under federal Medicaid guidelines) are based on the need for program services. A functional eligibility screen by definition must focus on functional impairments, i.e., needs for assistance. This means two things concerning the functional screen process and content:
The person being screened should consent to completion of the functional screen and its submission to DHS for screen development and aggregate data research. No screen should be completed without the person's signed informed consent. However, where the screen is the tool for determining need for services, the consumer needs to know that refusal to participate in the screening process could affect their eligibility for services. All information will be confidential within the Department and the screening agency.
The Department has chosen to make this screen the approved screen for CCS admissions for adults (the new children's screen will be used to determine CCS for children). It will also be the approved screen for COP eligibility for COP level 3 individuals with serious and persistent mental illness. For CCS, it is an annual requirement. It will remain voluntary for CSP at this time, however many counties may want to begin using the screen for CSP as it will give each program access to valuable data on the CSP population locally. For the first time, local agencies will have a mechanism to be able to sort caseloads by living situation, diagnosis, risk factors and ADL functional levels.
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. Screeners and 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 MH/AODA FS. Signed releases of information shall be included in the person's records as appropriate.
All aspects of the functional screen must comply with HIPAA (the Federal Health Insurance Portability and Accountability Act). The functional screen is a secure on-line computer application, with access limited to Department-assigned users verified by passwords.
Screeners should inform consumers of this, and of the following: A completed functional screen can be seen only by screeners of the screening agency. If MH/AODA screeners elsewhere in the state were to key in the individuals' name or Social Security Number, the program would inform them that a functional screen had been completed for that individual and would show the screening agency and date. That is all that can be seen; the content of the individual's functional screen cannot be seen by anyone except screeners of the screening agency (including the county agency if subcontracting).
Later, when the MH/AODA FS is fully implemented, it will form the basis of a comprehensive assessment by a MH/AODA provider. The provider will ask the consumer to sign a release of information, which allows the original screener to electronically "transfer" permission to see the completed functional screen content. If consumer chooses to sign the release, then the new case manager will read the functional screen to avoid asking all the same questions again. The new case manager will do a complete assessment building from the information shown in the MH/AODA FS.
Because the MH/AODA FS will (after testing) determine program eligibility, special requirements for quality assurance and screener qualifications are necessary.
Each pilot county will assign a "Screen Leader" who will be responsible for facilitating screen testing, gathering screeners' questions and feedback, and passing them on to designated state staff as soon as possible.
Every screener should test the MH/AODA FS thoughtfully - do not simply fill screens out, but really critique it. Test it on people with high needs, low needs, different sorts of needs, people now eligible for CSP (or BRC target groups 1 or 2) and those who are not.
Never guess or extrapolate on anything. When you encounter something not covered in these instructions - and you will - leave it blank and discuss it with your Screen Leader. The Screen Leader will call or e-mail designated state staff, who will answer the question and the update instructions as necessary. No one should make interpretations; instead, pass your questions on to state staff (usually through your Screen Leader). Questions can be answered locally only if they are found in these instructions. This will be most helpful to this project as we test the screen and the instructions for clarity.
All persons administering the functional screen must meet the following conditions:
Among the Screen Lead's roles is to oversee quality assurance. As the MH/AODA FS becomes more fully implemented, each agency will have on-going quality assurance methods, such as:
It is recognized (and shown in research) that all functional assessments or screens are imperfect. In particular, screeners should be aware of the following limitations found in national studies to be characteristic of all functional screens:
The MH/AODA FS will be repeatedly revised based on feedback and testing until it has 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. This challenge calls for extra vigilance to ensure the greatest possible accuracy in the functional screen. This is why screeners must be trained and experienced with the population, and why DHS and counties using the screen must have ongoing quality assurance processes.
Screeners should adhere to the following guidelines:
All screening agencies should have designated "Screen Leaders" to assist you with questions. Refer all questions to your Screen Leader, who will in turn refer questions to designated staff at the WI Bureau of Mental Health and Substance Abuse Services. (You can also contact designated State staff directly.) In this way, interpretations will be kept consistent and communicated to all screeners, and revisions can be made to the screen and instructions as necessary. It is absolutely critical that all screeners participate in this process.
For many items in the functional screen, functional status is ranked by the frequency at which the person needs help from other people. If someone is marked as needing help from others, then it is expected that either the person is getting the help (i.e., it would be in a individualized recovery plan) OR they are suffering negative outcomes or risk thereof from not getting the help.
Screeners should always think about inter-rater reliability before selecting answers on the MH/AODA FS. Do not mark your impression without first considering whether you have objective information that indicates that answer such that most other screeners would select it. Follow these important steps before selecting answers on the functional screen:
Screen Leaders should facilitate regular times for screeners to discuss screen questions, especially concerning cultural competence and inter-rater reliability. Screen Leaders can then share this feedback with Department staff for improving the screen and instructions.
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.
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 skilled interviewing and observation. If the proper answer is still not clear, discuss it with your Screen Leader, who can then, if necessary, ask DHS for guidance. If the consumer appears to be overstating their needs, ask:
If no hardship results from a lack of assistance, it implies that the person is in fact able to do the task himself or herself. This, of course, is the familiar "needs versus wants" distinction, but with the thought process clearly spelled out. Doing so shares the power with consumers, improves inter-rater reliability, and reduces at least some errors from assumptions or biases.
Sometimes MH/AODA practitioners recognize a need for help that the consumer does not recognize. Recovery principles reject the old "professional knows best" model and require that the consumer's perspective be central. Yet MH/AODA practitioners, particularly professionals, are responsible for noticing things that consumers might not notice, and for following up as much as the consumer allows. Example:
Individuals' responsibility and choice-making capacities are less clear when alcohol or drug addiction is involved. If a person's purchase and/or use of drugs or alcohol interferes with their ability to meet basic needs (food, clothing, and shelter) the screener will probably indicate some need for assistance with some tasks. The things to remember are:
Check a given frequency on the functional screen if it reflects actual needs as closely as possible; not merely what the person says they need or don't need, and not merely what the screener thinks, but something in between. It is what most screeners would agree should be in a service/treatment plan for that individual. Check a given frequency:
So, frequencies selected on the functional screen will usually match frequencies of MH/AODA case manager contacts with the individual. In this way, completing the functional screen is similar to developing an individualized service plan with someone. There are three exceptions:
Mental illnesses are often cyclical, with varying levels of symptoms and functioning. The MH/AODA FS is a mix of a "snapshot" view - the person's current status now and over the past few weeks - and an historical (or "movie") view looking over the past few months up to the past year or two. Every day MH/AODA practitioners (and consumers) make judgments based on this mix of snapshot and historical views, to determine the frequency of contacts and of help needed now and for the next few weeks or months. Of course people's needs will change, and of course predictions are only approximate, but they reflect expert judgment (and sometimes research data) of the frequency of interventions needed to promote recovery and prevent crises.
The MH/AODA FS is similar. For some "Community Living Skills," you are asked to indicate the approximate frequency at which help is needed. To make it easier to select answers, the answer choices have been reduced to "Independent," "Less than monthly," "1 to 4 times a month," "More than one time a week."
Less than monthly
1 to 4 times a month
More than one time per week
When completing the functional screen with someone preparing for discharge from a mental health facility within the next few days, complete the screen based on how the person is expected to function at home when they go home. This looking ahead is a normal part of discharge planning. So, if, for example, although the facility administers medications now, mark on the screen if the person will need help with medication administration after they go home. It will take additional time and talking with the individual, 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-based mental health/AODA services.