Module 9: Risk

Contents

• 9.1 Overview
• 9.2 Part A - Current Adult Protective Services (APS) or Elder Adult/Adult at Risk (EA/AAR) Client
• 9.3 Part B - Risk Evident During Screening Process

Objectives

By the end of this module you should be able to:

• Accurately complete the Risk section of the LTC FS.
• Describe "imminent risk of institutionalization" and why it's important.
• Identify when Risk Box 2 should be selected based on the person's level of risk if they would be without needed assistance from another person over a 6 to 8 week time period. Understand how Risk items relate to APS or EA/AAR services for a person being screened with the LTC FS.

9.1 Overview

The Risk Module of the LTC FS has been designed to do the following:

• Increase awareness of when a person may be at risk of institutionalization in a nursing home or Intermediate Care Facility for the Mentally Retarded (ICF-MR).
• Convey risk factor information to the LTC program.

Newly discovered cases of abuse, neglect, or exploitation should, in most instances, result in a referral to the APS or EA/AAR agency for investigation, case planning, and any necessary court related services. Screeners are expected to recognize signs of abuse, neglect, or exploitation, and to know how to respond appropriately. Wisconsin Statute 46.90 defines abuse as physical, sexual, emotional, restraint, confinement, and treatment without consent; neglect includes self-neglect or neglect of others or financial exploitation.

Hereafter, abuse, neglect, or exploitation will refer to any of the types listed above.

9.2 Part A - Current Adult Protective Services (APS) or Elder Adult/Adult at Risk (EA/AAR) Client

Current APS or EA/AAR Client Options:

• A1: Known to be a current client of Adult Protective Services (APS)
• A2: Currently being served by the lead Elder Adult/Adult at Risk (EA/AAR) agency

The A1 and A2 lists below contain common, illustrative examples. These lists are not all inclusive lists of examples.

Check all applicable boxes.

A1: (Known to be a current client of Adult Protective Services [APS]) is selected when:

• APS is pursuing or has established a temporary guardianship of the person or estate.
• APS is pursuing a guardianship of the person or estate.
• APS is pursuing a temporary or final protective placement order.
• APS is working with the person to evaluate their level of competency.
• APS is working with the person to evaluate their level of need for assistance.
• APS has filed for or obtained a temporary restraining order or permanent injunction for the individual at risk (Wisconsin Statute 813.123).
• Person has a court order for protective services or a protective placement.

REMINDER: Do not select A1 when a person's guardianship has been finalized and there is no protective placement order in place.

A2: (Currently being served by the lead Elder Adult/Adult at Risk [EA/AAR] agency) is selected when:

• The EA/AAR agency is working with the person to determine an appropriate response to the referral.
• The EA/AAR agency is working with the person to evaluate their level of need for assistance.

9.3 Part B - Risk Evident During Screening Process

A person's level of risk may be influenced by a number of factors. These may include choices they make about how they live their lives; whether they follow or disregard medical advice or accept or refuse assistance from others. On the other hand, a person may be at risk due to the action or inaction of another individual.

Generally, a competent person has the right to live with a level of risk others may not agree with or support. Regardless of choices the person makes, they may still have a need for assistance or supervision and that need should be recorded on the LTC FS.

Risk Evident During Screen Process Options:

• 0: No risk factors or evidence of abuse, neglect, or exploitation apparent at this time
• 1: The person is currently failing or is at high risk of failing to obtain nutrition, self-care, or safety adequate to avoid significant negative health outcomes
• 2: The person is at imminent risk of institutionalization (in a nursing home or ICF-MR) if they do not receive needed assistance or person is currently residing in a nursing home or ICF-MR
• 3: There are statements of, or evidence of, possible abuse, neglect, or exploitation
• 4: The person's support network appears to be adequate at this time, but may be fragile in the near future (within next 4 months)

At least one box in Part B must be checked. Check all applicable boxes, however if box "0" is checked, do not check boxes 1, 2, 3, or 4.

0: (No risk factors or evidence of abuse, neglect, or exploitation apparent at this time)

1: (The person is currently failing or is at high risk of failing to obtain nutrition, self-care, or safety adequate to avoid significant negative health outcomes)

The 'Check this for a person who' list contains common, illustrative examples. This list is not an all inclusive list of examples.

Check this for a person who:

• Is competent and refuses needed services.
• Is competent and mismanages their disease. For example, a person with insulin dependent diabetes mellitus who eats a diet high in sugar and carbohydrates.
• Is competent and participates in a high risk behavior. For example, a person prescribed continuous oxygen who smokes cigarettes. High risk behavior can include but is not limited to: poor nutrition, substance use, self-neglect, hoarding, refusing to take prescribed medications, or refusing to take medications as prescribed.
• Does not receive assistance from another person to complete any ADL or IADL task, but may need access to community services (e.g., a person needing access or assistance to apply for Food Stamps or Medicaid coverage).
• Is not at imminent risk that institutionalization (in a nursing home or ICF-MR) will occur within the next 6 to 8 weeks. However, without needed assistance the person may be at risk of entering a nursing home or ICF-MR beyond eight weeks.
• May be at risk of entering an Institute for Mental Disease (IMD) or hospital for psychiatric services.
• Risk Box 1 and Risk Box 2 often overlap. Risk Box 1 is broader than Risk Box 2, and can include a person for whom Box 2 does not apply.

2: (The person is at imminent risk of institutionalization (in a nursing home or ICF-MR) if they do not receive needed assistance or person is currently residing in a nursing home or ICF-MR)

This is federal language referencing when a person will be deemed nursing home eligible because they are at imminent risk of institutionalization if they do not receive needed assistance. Whether a person is at imminent risk of institutionalization is critical in determining whether he or she is eligible for a nursing home level of care. The federal Centers for Medicare and Medicaid Services has advised states that imminent risk of institutionalization means the person would require nursing home or ICF-MR care within 6 to 8 weeks, if community-based services were not provided. Screener should consider carefully whether the individual meets this criteria.

Risk Box 2 is critical in determining the person's eligibility for a nursing home level of care. As a result, the screener should consider selecting this box carefully.

Risk Box 2 also applies to and should be selected for a person currently residing in a nursing home or ICF-MR.

The selection of Risk Box 2 is appropriate if the person's health, without any needed assistance from another person, within 6 to 8 weeks, would likely decompensate to the point where they would need to consider entering a nursing home or ICF-MR to receive care. It's not an issue of whether the person states they will never agree to or never plans to enter a nursing home or ICF-MR.

When evaluating a person's level of risk, the screener should review the type and amount of assistance the person needs from another person. This review needs to consider how the person would be doing within 6 to 8 weeks if they went without any paid or unpaid assistance from others. Assistance includes needed care provided by a spouse, partner, friend, neighbor, or other person providing informal support. Whether a person is paid or not for providing assistance does not diminish the value of that assistance in helping a person live outside of a nursing home or ICF-MR.

The evaluation of a person's level of risk should not factor-in the person's need to use an adaptive aid to complete an ADL or IADL task. A person's independent use of an adaptive aid does not indicate a need for assistance from another person and does not indicate a level of risk.

REMINDER: When a person has a guardian or activated power of attorney for health care agent, do not automatically select Risk Box 2, without reviewing whether the person being screened would be at risk of entering a nursing home or ICF-MR.

The 'Check this for a person who' list and the 'Do NOT check this for a person who' list contain common, illustrative examples. These lists are not all inclusive lists of examples.

Check this for a person who:

• Has daytime incontinence daily and needs assistance with changing incontinence pads, if used.
• Has fallen more than once in the last month and sustained at least one injury requiring medical treatment.
• Is in the end-stage of a terminal illness.
• Due to a physical health exacerbation, had 3 or more hospital admissions in the last 6 months.
• Is currently residing in a nursing home or ICF-MR.
• Requires assistance from another person with three or more ADLs.
• Is residing in a licensed residential care facility and needs that level of care or supervision.
• As a result of developmental disability, degenerative brain disorder, serious and persistent mental illness, or other like incapacities, the individual will incur a substantial risk of physical harm or deterioration or will present a substantial risk of physical harm to others if protective services are not provided (Wisconsin Statute 55.08(2)(b)).
• Meets at least one of the criteria above, but they, their family members, or their authorized representative express unwillingness to have the person ever reside in a nursing home or ICF-MR.

Do NOT check this for a person who:

• Uses an adaptive aid or mobility device independently to complete an ADL or IADL task and as a result, does not need any assistance from another person to complete the ADL or IADL task.
• Only needs assistance with grocery shopping.
• Only needs assistance with snow removal or lawn care.
• Only needs assistance with the Transportation IADL.
• Is at risk of admission to a hospital or Institute for Mental Disease (IMD) for psychiatric services.
• Is at risk of entering a jail or prison.
• Voluntarily or by court order receives Chapter 51 community-based services. Chapter 51 services are in response to a person's need for treatment, not nursing home or ICF-MR care.
• Has a guardian of the person without first reviewing whether they are at risk of entering a nursing home or ICF-MR.

REMINDER: Risk Box 2 should not be selected based solely on a person's target group. Although a person's condition meets a target group definition, this is not in and of itself sufficient to meet the imminent risk criteria.

3: (There are statements of, or evidence of, possible abuse, neglect, or exploitation)

The screener should select this box to provide notification to the person's selected LTC program that the person is at risk.

Risk Box 3 should be selected when an applying minor child (age 17 and 6 months or older), adult, or an adult at risk is at imminent risk of serious bodily harm, death, sexual assault, or exploitation and is unable to make an informed judgment about whether to report the risk.

An adult at risk is defined as any adult with a physical or cognitive condition that substantially impairs their ability to care for their needs and who has experienced, is currently experiencing, or is at risk of experiencing abuse, neglect, or exploitation.

When Risk Box 3 is selected, the screener will most often make a referral for an investigation to the local APS or EA/AAR agency. According to Chapters 46.90 and 55.043, professionals are not required to make such a referral if they believe that doing so would not be in the best interest of the elder/adult at risk.

REMINDER: A competent adult cannot refuse to have a reporter make a referral for an investigation, but the adult can refuse to accept any services offered as a result of the investigation.

The 'Check this for a person who' list contains common, illustrative examples. This list is not an all inclusive list of examples.

Check this for a person who:

• Is an adult at imminent risk of serious bodily harm, death, sexual assault, or exploitation and is unable to make an informed judgment about whether to report the risk.
• Is being referred to the APS or EA/AAR agency for an investigation of abuse, neglect, or exploitation.
• Is not being referred to the APS or EA/AAR agency, because it is the screener's professional judgment that making the referral will not be in the best interest of the person.
  
  Example: Helen is a 90-year-old woman living alone, independent in all ADLs and IADLs, with no obvious cognitive impairment, physical impairment, or behavioral problem. Yet she is living in a tiny rundown house with 32 cats, filthy conditions, and broken plumbing. She says she eats three meals a day, doesn't mind the cat hair, cat urine and feces, etc., throughout the house, and doesn't need any help. She has no medical conditions or need for any health related services. She receives no assistance from another person. The screener should select Risk Box 1 and Risk Box 3, but not Risk Box 2.
  
  Risk Box 1 should be selected because Helen is at high risk of failing to maintain her safety adequate to avoid significant negative health outcomes related to her lifestyle choices.
  
  Risk Box 2 should not be selected because it is not clear Helen would be at risk of being functionally eligible to enter a nursing home within 6 to 8 weeks.
  
  Risk Box 3 should be selected because there is evidence of Helen's self-neglect related to her lifestyle choices.

4: (The person's formal and informal support network appears adequate at this time, but may be fragile in the near future [within next 4 months])

The 'Check this for a person who' list contains common, illustrative examples. This list is not an all inclusive list of examples.

Check this for a person who:

• Has an informal caregiver who is physically or emotionally exhausted from providing the person's care.
• Has an informal caregiver who will no longer be able to provide care (e.g., caregiver winters in a southern state, caregiver grandchild will be attending college out of the area, etc.).
• Is at risk of losing their residential care due to a change in their financial circumstances, the residential care facility closing, or their increased physical, cognitive, or behavioral care needs.

Last Revised: August 08, 2012
Wisconsin Department of Health Services
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