Adult Long-Term Care Functional Screen
Glossary of Acronyms (PDF) | LTC FS Paper Form (PDF)
LTC FS Instructions Module #3: LTC FS Basic Information/Screen Information/Demographics/Living Situation
By the end of this module you should be able to:
Demographic information collected for the LTC FS does not determine eligibility for LTC services. Demographic information is used for two purposes:
"Other" boxes are available in some instances to allow you, the screener, to fill in answers that may not be provided in the drop down boxes.
This is a read-only field that the application will fill in automatically. To transfer a screen to another agency because of enrollment, referral, or applicant's move to another county, the Transfer utility should be used.
Enter the date someone requested that a functional screen be done. For example, use the date a health care provider refers a consumer to your agency or the date a MCO refers a consumer to a resource center. If no one requested the functional screen, enter the date you start it. For example, use the date you start the screen when completing an annual screen or when completing a screen so than an existing participant has a baseline screen in your system.
Enter the person's date of birth in MM/DD/YYYY, as in 01/01/1909. LTC FS programming will not allow dates to be entered that make the applicant more than 150 years old or younger than 17 years, 6 months.
Select one option from the drop down box. There are two screen type options:
Enter the applicant's "permanent residence" address. If the person is now in a facility (nursing home, CBRF) that may or may not be their "permanent residence." If a person is now in a nursing home, but maintains their apartment in the community with the intention of returning to home in the next few weeks, their apartment would be their permanent residence-not the nursing home. Use your professional discretion to determine what is the applicant's permanent residence.
"Applicant" is the consumer you are screening as part of application for HCBW, Family Care, PACE/Partnership, or other long term care program. Include street number, street name, apartment number, city, and zip. Include telephone number if available.
For transient persons, enter the address they lived at the most in the last 6 months.
Select the appropriate county/tribe from the drop down box. In most cases these will be the same. In a few instances, persons may live in one county but another county/tribe is responsible for services, costs, and/or protective services. For the purposes of screening, residency is physical presence or the intent to reside.
This space is available for you to enter directions to the applicant/consumer's home. Keep your entries brief and succinct.
Select from the drop down box who (the applicant, a family member, friend, etc.) contacted the screening agency to refer this person for a Screen. If the screen is being completed as an annual screen, "2-Rescreen" from the drop down box.
Select the primary source (person) for screen information from the drop down box. If the primary source is not listed, select other and fill in the other box.
In most cases, the primary source for screen information should be the consumer. Often, screeners will also need to have collateral contacts with family, residential staff, health care providers.
In some instances information will be obtained almost equally from multiple sources. "Primary" means the majority, over 50 %. Please select the source that seems most accurate.
If the consumer uses an interpreter, the consumer -- not the interpreter-- is still the primary source of information.
This question is meant as a quality assurance reminder that screeners must not take shortcuts and complete a screen by only talking with caregivers, staff, etc. If the applicant could participate in the screen, the applicant should participate in the screen interview. If the person is not the primary source of information, it is expected that in most cases other parts of the screen will indicate significant cognitive limitations. It will also be used in research to explore differences in LTC FS depending on who provides information.
Select the place where the screen was conducted from the drop down box.
"Person's current residence" includes private homes, residential facilities, or nursing homes.
"Nursing home" includes ICF-IIDs and FDDs. Select "nursing home" if the nursing home is not the consumer's primary residence (i.e., they have a permanent residence elsewhere). If the nursing home is the consumer's primary residence, select "person's current residence" instead. We know that this question is not always easy to answer and rely on screeners' experience and expertise to select the most accurate answer.
"Temporary residence (non-institutional)" is intended for instances when consumer is staying with family or friends temporarily, for instance to recuperate from an illness or surgery. It also includes temporary stays in residential facilities, such as respite in a CBRF. Do not select this if the person is in an institution such as hospital or nursing home.
If you select "Other" please write a description such as Resource Center or county office.
Check ALL that apply.
If Medicare is checked, enter the person's Medicare number, and check box to indicate Part A or B or Medicare Managed Care as applicable. (Note: Medicare Managed Care is a new form of voluntary HMO Medicare called "Medicare Plus Choice." You may see it written as "M + C". If the person has Medicare Gold, check the "Medicare Managed Care" box.) The effective dates for Medicare Part A or B are optional to complete.
Private insurance includes employer-sponsored insurances (e.g., an HMO) available as a job benefit. BadgerCare and MAPP are forms of Medicaid. If the person is on BadgerCare or MAPP, enter this information under Medicaid with the number, and put a comment about this information in the Notes section.
"Black" refers to people having origins in any of the Black racial groups of Africa. It includes people who indicate their race as "Black," African American, Afro-American, Nigerian, or Haitian.
"Asian" refers to people having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent. It includes people who indicate their race or races as "Asian Indian," "Chinese," "Filipino," "Korean," "Japanese," "Vietnamese," or "Other Asian," or as Burmese, Hmong, Pakistani, or Thai.
"Pacific Islander" refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicate their race or races as "Native Hawaiian," "Guamanian or Chamorro," "Samoan," or "Other Pacific Islander," or as Tahitian, Mariana Islander, or Chuukese.
"White" refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as "White" or as Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.
"American Indian and Alaska Native" refers to people having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment. It includes people who indicate their race or races as Rosebud Sioux, Chippewa, or Navajo.
Check this box if the person does not meet any of the other racial definitions listed above and enter a comment to explain.
A person of Mexican, Puerto Rican, Cuban, Central, South American, or other Spanish culture or origin, regardless of race. (Hispanics and Latinos may be of any race.)
Leave this box unselected if no interpreter is needed.
Select the appropriate language if an interpreter is needed. If "Other," please type in the language needed. Human service and health care providers should always obtain interpreters when they are needed. This information will help show the extent of such needs, and will also help long term care programs better serve non-English speaking consumers.
The valid contact types to list here are:
If the person does have a valid contact to list, check the box and provide the contact’s name, phone number and full address. This information is needed to complete the screen, and to notify the contact of the consumer’s eligibility determination if appropriate.
If there is shared guardianship, you can write in the second guardian’s name and address in the Contact Information 2 area.
Representative payees and un-activated power of attorneys were not considered necessary for this screen and should not be listed in the Contacts section. Some people may have a durable power of attorney document drafted by their attorney that they think has been active from the time it was initially drawn up. However, such documents do not count as an "Activated POA for health care." Such a POA is "in force" when it is first filled-out, but the consumer makes all her own decisions until she loses capacity to do so. The HCPOA cannot make decisions for her until after she is incapacitated. That is what is meant on the screen by "activated." A health care POA is "activated" only after the consumer has lost decisional capacity. Activation is usually documented as a doctor's note or addendum to the HCPOA.
Select the appropriate answer from the drop down menu. If you need to select other, type in an explanation in the "other" box. Most living arrangements fit into one of the options provided. The "other" box should be used only if no other box is appropriate. If you need to provide additional information or clarification regarding the living arrangement use the notes section. For further clarification of the drop down menu choices:
Again, if you need to provide additional information about the living arrangement, please use the notes section rather choosing "other" when an existing option would be appropriate.
Select the appropriate answer from the drop down box menu.
The "Prefers to Live" question asks precisely and only for
the consumer's own stated preference. It will be used to see if long term
care consumers are living where they want to live and to track changes
over time. This question is asking the PERSON'S INFORMED PREFERENCE. Record
where s/he would like to live-not where anyone else wants them to live,
and not where you or others think is realistic. Screeners must take
the time to explain the person's options. The consumer cannot express a preference
if the screener has not informed them of their options first.
As another example, an old woman may say she "belongs in" a nursing home because she'd be too much of a bother anywhere else. The screener should take the time to ask what she would like, not what she thinks is reasonable.
Screeners should select the answer that most accurately reflects what the person is saying. An elder may articulate a preference for "an apartment with onsite services (RCAC, independent apartment CBRF)." But if a person with an intellectual/developmental disability is telling you that she just wants "a place of my own," then you select the most appropriate selection of "own home or apartment". Do NOT select "someone else's home or apartment" or an "apartment with services" even if that is probably what the person would get. The purpose of this question is to record what the person says, not what the system will provide or what you think s/he really needs.
Note: "Own home" can also include life estate situations where the elder has sold the property to another and retains the right to live there.
Select "Unable to determine person's preferred living arrangement" if the person cannot comprehend their options and/or cannot communicate their preference.
If the applicant's preferred living situation is not listed, select "Other" and please type in what the "Other" is, for possible screen revisions in future.
This question was added because screeners found completing the "Prefers to Live" too difficult to answer when the guardian or family disagreed with the consumer being screened.
Select the most appropriate option from the drop down box menu.
July 21, 2014