Adult Long-Term Care Functional Screen
Glossary of Acronyms (PDF) | LTC FS Paper Form (PDF)
Module #2: Long Term Care Functional Screen Target Groups
By the end of this module you should be able to:
The Long Term Care Functional Screen was designed to capture the needs of people who have a long-term care condition related to being a frail elder, having a physical or developmental disability, dementia (onset of any age), or a terminal condition. The length of time a person is expected to have a long-term care condition has a bearing on the program for which the person is eligible. In order for a person to be eligible for any home and community-based waiver (HCBW) program, the duration of his or her long-term care condition must be at least one year. In order for a person to be eligible for Family Care Nursing Home Level of Care (LOC) or Non-Nursing Home LOC, his or her long-term care condition must be expected to last 90 days or more.
Conditions for Functional Eligibility:
Any individual’s condition may meet the definitional requirements of more than one target group at a time. The LTC FS is designed to identify needs for individuals with conditions related to the following:
Selection of target group(s) relies on the professional judgment of the qualified screener when he or she applies federal and state statutory definitions for eligible target groups. As needed, a screener should consult with Decision Trees, his or her agency screen liaison, peers and other health care professionals when making target group assignments.
The following Decision Trees were developed to assist screeners when determining whether an individual meets the statutory definition of an eligibility target group:
Professional or Other Collateral Contacts
Frail elder means an individual aged 65 or older who has a physical disability, or an irreversible dementia, that restricts the individual’s ability to perform normal daily tasks or that threatens the capacity of the individual to live independently (Wisconsin Administrative Code, Chapter DHS 10.13(25m)).
For additional assistance in determining if a person’s condition meets this target group definition when he or she is over the age of 65 and has a co-morbidity such as a mental health or substance use issue, refer to the tool, Decision Tree for Frail Elders with Co-Morbidities (PDF, 25 KB)
Physical disability means a physical condition, including an anatomical loss or musculoskeletal, neurological, respiratory or cardiovascular impairment, which results from injury, disease or congenital disorder and which significantly interferes with or significantly limits at least one major life activity of a person” (WI Statutes Chapter 15.197(4)(a) 2).
“Major life activity” means any of the following: A. Self-care. B. Performance of manual tasks unrelated to gainful employment. C. Walking, D. Receptive and expressive language, E. Breathing, F. Working, G. Participating in educational programs, H. Mobility, other than walking, I. Capacity for independent living.” (WI Statutes Chapter 15.197(4)(a)1).
The target group of physical disability should be selected when a person’s physical or cognitive impairment meets the statutory definition, above.
REMINDER: If a person has a physical condition that is expected to limit their functional abilities, but that condition is an acute or short term condition (e.g., leg fracture, recovery from heart bypass surgery), the condition does not meet the definitional requirements of the Physical Disability target group.
Sensory Impairments and Physical Disability
When assessing a person’s ability to perform major life activities, a screener must consider the skills the person has developed or learned. For example, a person with deafness who has learned to read lips, to speak and to use both written and sign language at a level where he or she does not experience any significant limitation in performing major life activities listed above DOES NOT meet the Physical Disability target group definition on the basis of his or her hearing impairment. However, if a person could be taught those skills, but has yet to learn them, he or she might currently meet the Physical Disability target group definition.
Physical Disability and Mental Health or Substance Use Issues
REMINDER: A person can have a disability determination from the Social Security Administration and NOT meet a target group definition.
In truth, most limitations associated with being a frail elder are physical disabilities, so in many instances both target group definitions might apply. For example, arthritis may be considered age-related in an older person, but in a younger person may be considered a physical disability. Use the following examples as a guide:
A person is considered to have an intellectual disability if he or she has - (i) A level of intellectual disability described in the American Association Intellectual and Developmental Disabilities' Manual on Classification in Intellectual Disability, or (ii) A related condition as defined by 42 CFR 435.1009 which states, “Person with related conditions” means individuals who have a severe, chronic disability that meets all of the following conditions:
(a) It is attributable to:
(b) It is manifested before the person reaches age 22
(c) It is likely to continue indefinitely
(d) It results in substantial functional limitations in three or more of the following areas of major life activity: self-care; understanding and use of language; learning; mobility; self-direction; or capacity for independent living.
Review of a person’s county, medical or school records may be helpful in making target group determination. in addition to health care records. A person’s family members or guardians often retain copies of such documentation. When making an intellectual/developmental disability (I/DD determination), obtain essential information such as IQ score and diagnosis and use the Decision Tree for the Intellectual/Developmental Disability per Federal Definition Target Group (PDF, 20 KB) tool to work through the determination process. If questions arise while working through the decision tree, first consult with your agency’s screen liaison. If further assistance is needed, consult with DHS screen staff.
If a person has an intellectual/developmental disability, but does not meet the Intellectual/Developmental Disability per Federal target group definition, the screener must review whether the person’s condition meets the Intellectual/Developmental Disability per State Definition target group definition.
If a person with an intellectual/developmental disability has no other health condition, he or she must meet the Intellectual/Developmental Disability per Federal Definition target group definition in order to be eligible for the CIP 1A, CIP 1B or the IRIS Medicaid waiver programs.
NOTE: Some school districts refer young adults with a diagnosis such as learning disorder, attention deficit disorder, attention deficit hyperactivity disorder, behavioral disorder or an emotional disturbance to ADRCs. In some instances, it is not apparent whether a school-age person’s condition meets the I/DD per Federal Definition or meets the I/DD per State Definition target group definition. To assist in making these determinations, use the related decision tree to evaluate whether the person’s diagnosis, functioning and need for active treatment meet the I/DD per Federal Definition target group definition.
REMINDER: A screener must confirm a diagnosis of Intellectual Disability directly with a health care provider or through written information found in the medical record, a Children’s Long Term Support (CLTS) Functional Screen or through a disability determination diagnosis made by the Social Security Administration.
Developmental disability' means a disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome, intellectual disability, or another neurological condition closely related to an intellectual disability or requiring treatment similar to that required for individuals with an intellectual disability, which has continued or can be expected to continue indefinitely and constitutes a substantial handicap to the afflicted individual. 'Developmental disability' does not include senility which is primarily caused by the process of aging or the infirmities of aging” (WI Statutes Chapter 51.01(5)(a)).
Wisconsin's definition of DD is broader than the Federal definition, in that it does not include the restrictive clauses “b” (onset before age 22) and “d” (substantial functional limitations) that are found within the Federal definition. In order to be eligible for the home and community-based waivers for persons with intellectual/developmental, the consumer must meet the I/DD per Federal definition target group definition.
If a person condition meets the I/DD per Federal Definition target group definition, he or she will also meet the State definition. However, a screen should check that the person meets the FEDERAL definition on the LTC FS target group section, only.
When making target group determinations for a person with an I/DD, it is helpful to obtain any related medical information and then work through the Decision Tree for Decision Tree for Intellectual/Developmental Disability per Federal Definition Target Group. Examples of related medical information include documentation from a health care provider, medical record, a Children’s Long Term Care (CLTS) Functional Screen or other confirmation of the person’s full-scale IQ or diagnosis. For additional assistance, consult with DHS screen staff. If you do not have essential information, refer the individual being screened to a physician or psychologies, as discussed above.
REMINDER: If a person with an intellectual/developmental disability qualifies for a long term care target group ONLY by meeting the definition of I/DD per State Definition, he or she may be eligible for managed long term care in Wisconsin, but will not be eligible for CIP 1A, CIP 1B or the IRIS Medicaid waiver programs.
Dementia means Alzheimer's disease and other related irreversible dementias involving a degenerative disease of the central nervous system characterized especially by premature senile mental deterioration and also includes any other irreversible deterioration of intellectual faculties with concomitant emotional disturbance resulting from organic brain disorder (WI Statues Chapter 46.87(1)(a)).
Statute does not limit organic brain disorder to the specific diagnosis “organic brain syndrome.”
Whether a person’s dementia is irreversible is not always discernible by diagnosis alone. For instance, alcoholic dementia or drug-induced dementia may or may be reversible. In these instances, a screener may need to consult with a health care provider to confirm whether the dementia experienced by a person being screened is irreversible.
The following is a list of some common conditions with irreversible dementia:
Note: The preceding list is not all-inclusive; other irreversible dementia diagnoses exist and new irreversible dementia diagnoses are identified on a regular basis. Consult with a health care professional to confirm the irreversible nature of a diagnosis that is not listed above.
The diagnoses of Mild Cognitive Impairment or Cognitive Impairment NOS are not irreversible dementia diagnoses and should be recorded as E:6, Other Brain Disorders on the LTC FS.
It may be difficult to differentiate between a person’s organic brain disorder and a mental illness or substance use issue he or she may be experiencing. In these instances, a screener may need to consult with a health care professional to verify the cause of the person’s dementia-like symptoms.
The Alzheimer’s Disease or Other Irreversible Dementia (onset of any age) target group is listed as a separate target group in order to clearly identify individuals who are younger than age 65 with dementia who may not meet criteria for any other target group. However, when a person with dementia who is younger than age 65 meets criteria for more than one target group, mark all applicable target groups.
In most long term care programs, traumatic brain injury is included with the Physical Disability target group, even if the resulting symptoms are only cognitive or behavioral.
A person with brain injury may meet the Federal definition of I/DD if their injury occurred before age 22. If the brain injury occurred after age 22, the person’s condition may meet the State definition of I/DD* but not the Federal definition.
*A special rule only for the State I/DD definition: If the injury to the brain is vascular in origin it must have occurred prior to age 22 in order for the person’s condition to qualify as meeting the definition.
Refer to the Brain Injury Target Group Decision Tree to determine whether an individual meets the Physical Disability target group definition in addition to the I/DD target group definition.
Functional eligibility determination for the Wisconsin Brain Injury Waiver Program requires a process that is more in-depth than completion of the LTC FS. When appropriate, an agency should refer individuals with brain injuries to that program.
For the purposes of the LTC FS, terminal condition is defined as a condition with which a person’s death is expected within one year from the date of his or her screening.
If this target group is selected, the screener must also select both K3: Terminal Illness (prognosis less than or equal to 12 months) on the LTC FS Diagnosis Table and the associated diagnosis which has created the terminal condition (e.g., J2: Cancer in the past 5 years). Written documentation from the physician of the person being screened that verifies the terminal nature of the condition is not required.
A screener should select “Yes” for the box on the LTC FS Target Group Section that asks, “Is the condition related to the eligible target group expected to last more than 12 months OR does the person have a terminal illness?”
For the purposes of the LTC FS, severe and persistent mental illness (SPMI) is defined as a mental illness which is severe in degree and persistent in duration, which causes a substantially diminished level of functioning in the primary aspects of daily living and an inability to cope with the ordinary demands of life, which may lead to an inability to maintain stable adjustment and independent functioning without long-term treatment and support and which may be of lifelong duration.
A person with a diagnosis of schizophrenia will likely meet the SPMI target group definition. The diagnosis of SPMI encompasses a wide spectrum of psychotic and other severely disabling psychiatric diagnostic categories, but does not include organic mental disorders or a primary diagnosis of an alcohol or substance use issue.
For example, a person who is stable, functional, and treated with anti-depressant medication on a short-term basis for situational, grief-related depression, would not meet this target group’s definitional requirements. Conversely, a person with a long-standing diagnosis of schizophrenia who refuses treatment, is frequently unstable and hospitalized, would meet this target group’s definitional requirements.
A person with a diagnosis of personality disorder and persistent difficulty in certain functional areas of life which affect his or her overall quality of life (e.g., inability to follow through with health care, inability to sustain relationships, vocational goals or cannot perform activities of daily living with consistency) may meet this target group’s definitional requirements.
Although severe and persistent mental illness is included as a LTC FS target group, eligibility for Wisconsin’s publicly-funded long term care programs such as Family Care, PACE/Partnership, CIP 1A/1B and COP-Waiver requires that consumers also have LTC conditions related to another primary LTC target group (e.g., Frail Elder, Physical Disability, Intellectual/Developmental Disability). Severe and persistent mental illness cannot be the only LTC target group selected if a person is to be found eligible for publicly-funded long term care programs.
“Co-morbidity” means having more than one diagnosis; in this document it refers to having a mental illness and/or substance use diagnosis along with physical disability, being a frail elder or intellectual/developmental disability.
When a person has a co-morbidity, use either the Decision Tree for Frail Elders with Co-Morbidities or the Decision Tree for Physical Disability with Co-Morbidities when making his or her target group assignment. Follow these steps when using these decision trees:
First, determine whether the person meets statutory definitions for eligibility for at least one LTC FS target group, such as Frail Elder, Physical Disability, I/DD, dementia, or terminal condition. Focus only on the person’s physical, medical, or cognitive condition and disregard his or her mental illness or substance use issues.
If the person’s physical, medical or cognitive impairment limits his or her ability to complete everyday activities and meets a target group definition for eligibility, select all of the applicable target groups.
Although a person may have mental health or substance use issues, he or she may be eligible for long-term care programs in Wisconsin if he or she meets the definition of eligibility for at least one target group for publicly-funded long term care and has functional limitations (e.g., needs help with ADLs/IADLs) that are related to condition that qualified him or her for target group. The screener does not need to determine which diagnosis is PRIMARY, nor does he or she need to determine the reason for the ADL/IADL limitations. A person whose primary diagnosis is mental illness could be eligible for a long term care program, if his or her other condition(s) meets a long-term care program eligible target group and he or she has ADL/ IADL deficits. Remember that to meet a target group, the person has to have deficits related to that particular target group definition.
If a person has ONLY mental health and/or substance use issues, he or she is INELIGIBLE for publicly-funded long term care programs in Wisconsin. There is no target group specifically designated for individual whose sole condition is related to substance use issues. If a person’s mental health issue meets the SPMI target group definition, the screener should select that target group and complete the remainder of the LTC FS based on the persons need for assistance. The screening agency should refer the person to other applicable programs.
Second, proceed with completion of the screen to determine if the person is functionally eligible for a target group that is permissible within one of Wisconsin’s publicly-funded long term care programs. Once all applicable target groups are selected for a person, the remainder of the LTC FS should be completed to reflect the person’s need for assistance from another person, even if the assistance is related to his or her mental illness.
Target group definitions are statutory in nature and must be followed. When a screener has found that a person’s functional limitations do not meet a target group, the screener selects the None of the above-No Target Group option when entering the person’s LTC FS.
Reminder: A person may have a disability determination from the Social Security Administration and NOT meet a target group definition.
A person must be 18 years of age or older to participate in a publicly-funded long term care program for which the LTC FS determines eligibility. However, once a person reaches the age of 17 years and six months, the LTC FS may be completed. This early screening option assists with transition planning for youths entering the adult long term care system. If a screener enters a date of birth that indicates that a person being screened is less than 17 years and six months of age, the LTC FS computer application will not allow the screener to proceed with an adult functional eligibility determination.
Included in the Target Group section of the LTC FS are three questions that require a response of either YES or NO.
Question 1. Is the condition related to the eligible target group expected to last more than 12 months OR does the person have a terminal illness? For purposes of the LTC FS, a terminal illness is defined as a condition where death is expected within one year.
Question 2. Is the condition related to an eligible target group expected to last more than 90 days? Most short term injuries (e.g., from bone fracture) and a related need for assistance from another person would not be expected to continue beyond 90 days.
Question 3. Does the applicant have a disability determination from the Disability Determination Bureau or the Social Security Administration? In addition to YES or NO, PENDING may be selected as a response to this question. If a person has a presumptive or final disability determination, the screener should select YES in response to this question. PENDING is the correct response when a final decision has not been made about the level of disability for a person who has applied to the Social Security Administration (SSA) for disability-related benefits.
While a young person is transition from a Children’s Long Term Support Waiver program to a publicly-funded long-term care program for adults, a screener should select YES in response to Question 3. A child’s disability determination from SSA is valid until he or she reaches 22 years of age. When a young adult who has been participating in the Children’s Long Term Support Waiver program reaches the age of 18, he or she often transitions to long term care program that serves adults. Although a rare occurrence, it is possible that a child with a children’s disability determination from SSA may not meet adult disability determination criteria. A child may first apply for an adult disability determination with the SSA when he or she reaches 18 years of age.
In order to participate in a publicly-funded long term care program in Wisconsin, a person must have an adult disability determination from SSA. Although a lack of disability determination does not affect the person’s level of care determination and functional eligibility, it is required in order to meet the programs’ Medicaid non-financial eligibility requirements.
This screen item should only be completed for an individual pursuing participating in one of the following long term care programs: CIP 1A, CIP 1B, COP-W, CIP II, or Include, Respect, I Self-Direct (IRIS).
Select the appropriate waiver type from the drop-down box. This question does not determine waiver eligibility, but allows appropriate agencies to access and review screens for quality assurance purposes.
This question also applies to recertification screens for persons already on a waiver, but who are being screened for the first time using the LTC FS. If the person does not meet waiver level of care or will not be served in a waiver at this time, do not select a waiver type.
February 25, 2014