1.2 The CLTS FS Determines Functional Eligibility for Long-Term Support Programs
1.3 The CLTS FS is Required for Long-Term Support Functional Eligibility Determinations
1.4 The Screening and Interview Process
1.5 Screening and Re-Screening Requirements
1.6 Reliability of Screen and Screeners
1.7 Requirements for Quality Assurance and Screener Qualifications
1.8 Screening Limitations
1.9 Impending Discharge Back to Home
The Wisconsin Children's Long-Term Support Functional Screen (CLTS FS) was developed by a Department of Health Services (DHS) workgroup over the course of three years (2001 - 2003), as part of the Wisconsin's Children's Long-Term Support Redesign project. The goal of the redesign project was to improve access, coordination, choice, quality, and financing of the long-term support system to better serve children and families.
The CLTS FS was built upon the success of Wisconsin's Long-Term Care Functional Screen (LTC FS) which determines eligibility for most of Wisconsin's adults with long-term needs, frail elders and people with physical and developmental disabilities. Based on testing from 2003-2005, the CLTS FS has proven extremely accurate and reliable. The CLTS FS provides functional eligibility determinations for seven programmatic areas, four functional levels of care (explained below) and three target group designations for children from birth through 21 years of age. For more information related to the screen's reliability and validity, training to become a certified screener, and reference materials for certified screeners, see www.dhs.wisconsin.gov/FunctionalScreen.
The CLTS FS shares the same secure web-based infrastructure as the LTC FS, and adult Mental Health screen, however, the CLTS FS functions independently of these screens and is more complex because:
- It appropriately adjusts questions for children as they develop from birth through young adult (until age 22 years);
- It determines functional eligibility for multiple long-term support programs;
- It determines multiple levels of care and target groups; and
- Specific diagnoses are required for functional eligibility for some programs.
The CLTS FS has been designed, operated, evaluated and improved through a rigorous quality management system. The CLTS FS was designed with skilled clinicians from each of the programmatic areas, as well as others with experience related to child development. The initial success of the screen is attributed to the willingness of program staff, as well as county agency partners, to build and test the screen throughout its development. Extensive validity testing and inter-rater reliability testing was completed with these state and county partners. The testing results demonstrate that the screen provides accurate functional eligibility results across multiple levels of care as well as six programmatic areas. Although formal start-up testing of the CLTS FS is complete, processes have been established to try and prevent a child from being wrongfully denied functional eligibility. State staff continue to: address screener questions, review questionable functional eligibility results, provide ongoing quality oversight, develop screen changes, develop clear written instructions, provide comprehensive training to new screeners, offer daily support and on-going training for certified screeners and notify screeners of changes or improvements to the screen in order to maintain a high level of validity and reliability.
Maintenance and improvement of the functional screen is an interactive process. Continuous quality improvement includes ongoing discovery activities including random reviews of individual children's screens related to accuracy and documentation related to the screener's responses, an analysis of individual screens and data, for example comparing screen functional eligibility to previous functional eligibility determinations, as well as trend and aggregate data to determine if screen results remain consistent and reliable. These efforts assure that screen issues are identified and corrected in a timely manner.
The components of the CLTS FS are as follows:
- Individual Information: Screen identifying data, child's demographic information, residential setting, legal concerns, and citizenship and identity verification;
- Contact Information: Contact information for child's parents, guardians and other significant individuals;
- Diagnoses: Child's diagnostic information pertaining to a disability determination, transplant, diagnoses, and primary care physician;
- Mental Health: Mental health status information regarding duration of condition, severe symptoms, needed services, rare and extreme circumstances;
- Behaviors: Listing of relevant behaviors to indicate frequency, intervention and duration. Behavioral categories of High Risk, Self Injurious, Aggressive/Offensive and Lack of Behavioral Controls;
- Activities of Daily Living: Specific items available to indicate need for support in bathing, grooming, dressing, eating, toileting, mobility and transfers. Provided by specific age groups;
- Instrumental Activities of Daily Living: Specific items available to indicate need for support in communication, learning, social competency, meal preparation, and money management. Provided by specific age groups;
- School and Work: School attendance and compliance, high school related data, support needed to transition to adult services, employment information and preferences; and
- Health Related Services: Medical and skilled nursing information including terminal conditions, tracheostomy, ventilator, dialysis, IV, oxygen, respiratory treatments, TPN, tube feedings, therapies, colostomy, catheter and wound or site care.
The CLTS FS also includes additional information not directly related to the functional eligibility of the child. These other factors have been added to track critical national outcome data in areas such as the child's status with a primary health care provider (a Medical Home) and Transition planning services and supports.
The CLTS FS provides the opportunity for certified screeners to describe the needs of children with long-term support needs living at home, in substitute care settings, or in institutions as these factors relate to functional eligibility required for various children's long-term support programs. The following are the "screen development criteria" that guided these decisions:
- Objectivity and Reliability: The CLTS FS is designed to be as objective as possible in order to reach the highest possible "inter-rater reliability" (two screeners would answer the same way for a given child). Subjectivity is minimized to ensure fair and proper functional eligibility determinations, as well as to provide statewide consistency in eligibility determinations.
- Accuracy: Functional eligibility determinations must be correct and must match current accurate decisions, in every instance.
- Brevity: The CLTS FS only determines functional eligibility to as it relates to the level of care criteria associated with each program's functional eligibility requirements. It serves as a baseline for more in-depth assessment to develop a service plan that reflects each child's and family's strengths, values, and preferences.
- Inclusive: Children of all ages, with emotional, cognitive, physical, or developmental disabilities, with or without skilled nursing needs, in any setting from homeless to hospitals or institutions, can be accurately screened with the given choices for each developmental and activity subsection.
- Clarity: Definitions and answer choices, including diagnoses and nursing needs, must be clear to screeners with a broad array of professional backgrounds and experiences.
The CLTS FS determines functional eligibility for people from birth to age 21 years inclusive, and where relevant, a specific "Level of Care," and Target Group (explained below) for seven different programs:
- Comprehensive Community Services;
- Community Recovery Services;
- Community Options Program;
- Family Support Program;
- Katie Beckett Medicaid TEFRA Program;
- Medicaid Home and Community-Based Services Waivers; and
- Mental Health Wraparound Services.
The Centers for Medicare and Medicaid Services (CMS) requires that "Target Groups" not be combined within one waiver. Therefore, there are three complimentary CLTS Home and Community-Based Services Waivers (Developmental Disabilities, Physical Disabilities, and Mental Health).
The screener will collect relevant functional eligibility information in the course of meeting a child and their family. Again, the CLTS FS is not a comprehensive assessment; rather it is a review of key information related to functional eligibility. Once the CLTS FS fields are complete, the computer functional eligibility logic is able to determine which of the four institutional equivalent Level of Care requirements are met. The four institutional Levels of Care are:
- Hospital (HOS),
- Psychiatric Hospital (SED),
- Nursing Home (NH), and
- Intermediate Care Facility for Individuals with Intellectual Disability = Developmental Disability (DD)
A Level of Care (LOC) is required for both Medicaid Home and Community-Based Services Waivers and the Katie Beckett Medicaid Program. Additionally, the related Target Group(s): Physical Disability, Mental Health or Developmental Disability, for the CLTS Home and Community-Based Services Waivers is determined.
The CLTS FS also provides a functional eligibility determination for the Family Support Program, Comprehensive Community Services, Community Recovery Services, Community Options Program, and Mental Health Wraparound. The screener does not need to select program(s) for which they want to determine functional eligibility. The screen automatically reviews the child's functioning in comparison to functional eligibility criteria for all programs. Functional eligibility results may show that a particular child meets functional eligibility for some programs but not functional eligibility for other programs. The CLTS FS does not determine program eligibility, only one piece of program eligibility (functional eligibility).
If functional eligibility results do not seem appropriate to the screener based on their knowledge of the level of care requirements and their knowledge of the child's abilities, or if the screener has any screen completion questions, then the screener must contact the CLTS FS Coordinator at the Department of Health Services. This is critical to the accuracy and reliability of each individual Functional Screen.
If a young adult is seeking Adult Long Term Care Programs, the Adult Long Term Care Functional Screen should be used to determine functional eligibility. For other programs that provide support to young adults from 18-22 years of age, the screener must select the screen that best matches the types of services the person is seeking from the waiver. For example, if the needed services are primarily adult related or administered programs, then the adult functional screen should be used.
The Functional Screen tools are intended to streamline initial and ongoing functional eligibility determinations and to reduce duplicative efforts. Therefore, when a person is within the transitional ages of 18 to 22 years of age, long-term care programs will only accept the results from the most appropriate functional screen. For example if a person is 19 years old and using one of the Medicaid CLTS Waivers, then the CLTS FS should be used for this as well as other programs such as COP and FSP. If another 19 year old is using the Medicaid CIP Waiver, then the Adult LTC FS should be completed and these results will serve as results for COP and FSP.
Social Security Disability Determination
A child must have a Social Security Administration (SSA) determination of disability for the Katie Beckett Medicaid Program and most Medicaid Home and Community-Based Waivers eligibility. If a child has a confirmed disability determination the CLTS FS will issue actual functional eligibility results. If the child has not had such a determination, or if their disability status is unknown, the screen will display "pending a disability determination" on the eligibility results page.
Other Functions of the CLTS FS
The CLTS FS gathers and stores all information collected in the functional screen process. These data serve purposes in addition to an individual child's determination for program functional eligibility. The data also:
- Serve as a foundation for the comprehensive assessment related to long-term supports and services selected by the parent(s).
- Provide data for quality assurance and improvement studies for the Department of Health Services (DHS) and long-term support programs utilizing the CLTS FS.
- Provide data to counties and, as appropriate, to provider agencies on eligible children and on encounter data and timeliness of the eligibility process.
- Provide data for national and state-level outcome measurements.
Parent(s) should provide informed consent to participate by providing information for a functional screen functional eligibility determination. This includes the requirement that all information provided must be accurate and truthful and that failure to be accurate and truthful has consequences. The parent(s) may refuse to provide needed information and may refuse to have a CLTS Functional Screen completed. However, the consequence of this decision is that the child may not be able to access Medicaid and long-term support services. The parent(s) should also be informed that information gathered during the screening process is confidential, that information will be submitted to DHS for aggregate data analyses and that information may have an affect on their functional eligibility or ineligibility for other programs. No screen should be completed without the parent(s) consent.
Screening agencies shall comply with confidentiality and Health Insurance Portability and Accountability Act (HIPAA) rules and requirements, and shall obtain a signed release of information from the child's parent(s) or guardian(s) for the use of medical records, educational records and other records as appropriate before conducting the CLTS FS. Signed releases of information shall be included in the child's records when appropriate.
Any information collected for the screen or during the screening process is confidential. Information is to be treated with the same requirements for confidentiality within the current system of long-term supports. If one agency completes the screen but the family wants the results to be considered by another relevant long-term support system, separate consent to share confidential information may be required.
Example: A family contacts the Family Support Program to apply for these supports and services. In the course of completing the screen, it appears that the child will also be COP and Medicaid Home and Community-Based Services Waiver eligible. The CLTS FS information can be shared between members of the same agency on a need-to-know basis. However, if the lead agency for COP or the Waiver is different, a release of information will need to be obtained from the family before access to CLTS FS information is granted to a different agency. In addition, the screener can only share with the family the screen results for the long-term support program that their agency administers.
All information can be viewed at the state level on a need-to-know basis. This includes quality management activities at an individual and aggregate level. As part of the initial consent process, parent(s) will be informed that information entered into the screen will be entered into a state level system. However, these results will only be viewed at an individual level when there is a need-to-know.
The screening process requires a face-to-face meeting with the child being screened. This typically occurs with a parent present. Ideally, the required face-to-face interview should take place in the family's home with the child present. This home-based visit is required if the family is applying for the Katie Beckett Program. It may take more than one contact with the child and parents to complete the CLTS FS.
There is a paper version of the Functional Screen. This is intended as a reference tool only. The paper version is not intended as an interview guide or application form for families. Certified screeners may use existing agency application and assessment forms to assist them in collecting necessary information about the child's and family's strengths and needs. The CLTS FS sections can be completed in any order within the web-based application. This facilitates the use of the screen with a variety of existing application forms and assessment tools.
The certified screener should use their best clinical interview and assessment skills to gather the needed information to complete the CLTS FS. The screener will need to ask questions in a variety of ways and use collateral informants as necessary. Collateral informants include other family members, Birth to 3 Program or school staff, formal or informal caregivers, health care providers, and other agencies providing services to the child. The screener must always have a face-to-face meeting with the child, even if other informants are contacted for information.
Once the screener gathers all needed information, the CLTS FS is completed using the web-based application. Entering information into the CLTS FS is completed separately from the interaction with the family and child. It is critical that the certified screener's responses are accurate and verified from a variety of sources as necessary. The screener must strive to use objective clinical judgment and this could be affected by completing the screen with the family present. The CLTS FS is a tool for certified screeners to ensure smooth and timely access for the child and family to long-term supports. It does not replace strong clinical and interaction skills to form a relationship with the child and family.
The Medicaid Home and Community-Based Services Waiver, the Katie Beckett Medicaid Eligibility Program and the Family Support Program require an INITIAL screen to establish functional eligibility prior to receiving services. A RESCREEN, or recertification, is required thereafter to ensure continued functional eligibility.
It is critical, whenever the condition of a child enrolled in a long-term support program substantially changes, that the CLTS FS be updated using a RESCREEN and the functional eligibility logic recalculated. This will determine whether or not the child's change in condition impacts their level of care, target group or functional eligibility by program.
The CLTS FS can be done more often than yearly. This includes whenever a screen is transferred, the child's condition changes or other important changes need to be documented. It is important that when a RESCREEN is done, that the screener review the child's previously completed screens for information and historical perspective. The data warehouse maintains all information from previously calculated screens so that the longitudinal perspective is preserved when a new version of the screen is created.
The CLTS FS has been established as a reliable functional eligibility tool when used by certified screeners who follow established policies and procedures including verification of diagnosis, health related services, activities of daily living and instrumental activities of daily living. Because a child's developmental functioning and expectations change as the child ages, extra vigilance to ensure the greatest possible accuracy in the CLTS FS must be utilized.
Screeners must adhere, at a minimum, to the following guidelines:
- Screeners must read and closely follow screen definitions and instructions. Screeners are notified whenever changes or updates are made to the screen or instructions. Screeners are responsible to adapt their use of the CLTS FS per these instructions.
- Screeners must address each question carefully to assure accuracy, even when a screener knows a child well.
- Screeners must always select the answer that most accurately describes the child's functioning. The functional eligibility logic is very complex and uses information gathered from all sections of the CLTS FS. Therefore, it is important that a screener not second guess how their responses may interact for a particular child.
- Screeners are prohibited from altering a response to any particular question in an attempt to make a child functionally eligible or ineligible. The response to a single question will not give specific results. Rather the screen logic compiles all responses and compares this to functional eligibility, level of care and target group information. If a screener gets an unexpected result for any of these areas, the CLTS FS Coordinator must be contacted.
- Screeners are expected to refer all questions and concerns to the CLTS FS Coordinator. This assures consistent interpretation of the CLTS FS. Consistent responses are critical for ongoing inter-rater reliability. Changes and corrections as a result of questions are then communicated to all programs utilizing the CLTS FS. This information may also lead to revisions in the CLTS FS assuring ongoing quality improvement.
As discussed above, the CLTS FS determines a child's functional eligibility for Wisconsin's long-term support programs, including:
- Community Options Program
- Community Recovery Services
- Comprehensive Community Services
- Family Support Program
- Katie Beckett Medicaid Program
- Medicaid Home and Community-Based Services Waivers
- Mental Health Wraparound Services
Special requirements for quality assurance and screener qualifications are necessary because the CLTS FS helps determine functional eligibility. The screener must have experience regarding the unique conditions, development, needs, and functioning of children with significant disabilities. The screener must also complete training to be a certified screener, as well as on-going review of their reliability as a screener.
Parallel to the screener qualification, training, and certification requirements stated above, there are quality performance and assurance requirements to ensure consistency and accuracy of administration of the screen. There are three levels of CLTS FS quality assurance.
1.) Individual Screener Quality Assurance Review
It is the screener's responsibility to be objective in screening, to be informed of the instructions, and to corroborate information gathered from the child's family. The CLTS FS Coordinator can address questions that arise as a screener completes an individual child's CLTS FS. Screeners should contact the CLTS FS Coordinator whenever they obtain a different result than expected for a child based on the requirements of the level of care criteria. This includes functional eligibility and non-eligible results, as well as any discrepancy in the expected target group or level of care. Screeners should also seek clinical consultation on any individual screen question that is complex or confusing for a given child's circumstances. Screeners are held accountable for their results. This could result in a disallowance of state or federal funding and resulting recoupment.
2.) Agency Level Quality Assurance Review
Agencies are held accountable for the accuracy of all screens completed by their staff. Inaccurate and poorly completed screens or screens manipulated for a particular outcome may result in a disallowance of state or federal funding and resulting recoupment.
The methods each agency should be conducting will, at a minimum, include:
- Participating in all required inter-rater reliability testing;
- Assuring appropriate training, mentoring, and monitoring of new screeners;
- Reviewing a random sample of CLTS Functional Screens for accuracy and consistency on an on-going, agency-wide basis;
- Completing all required reports;
- Following up on all quality assurance inquiries and providing proof of proper documentation for all responses on the CLTS FS; and
- Consulting with CLTS FS Coordinator regarding any screen results or inaccuracies discovered through these activities.
3.) State Level Quality Assurance Review
The Department of Health Services reviews screens and utilizes quality assurance methods during quarterly and annual reviews. This includes a series of analyses and comparisons of all agencies' screens. Each agency receives a report following such reviews, including a request to the screening agency to correct and amend any screen errors or inconsistencies.
Research shows that the following limitations occur in all functional assessments or screens:
- Self-reports (from children or parents) can be inaccurate.
- Different people will describe a child's abilities, needs, and problems very differently.
- People often provide different information at different times and/or to different screeners.
- People may observe different functional abilities and needs over time or across different settings (e.g., home or school), making it difficult to select an accurate answer.
- Screen answers vary somewhat depending on whether the screener knows the child.
- Screen answers vary somewhat depending on the environment in which the screener observed the child.
- While objectivity is the ultimate goal, some subjectivity may remain in some questions.
Strategies to Minimize Screening Limitations—This section outlines guidelines to increase inter-rater reliability of the CLTS FS despite the limitations noted above.
A. Apparently Inaccurate or Inconsistent Reports Related to the Child's Needs
Functional eligibility screens cannot be based solely upon child or family self-report; nor can they be merely screener's judgment. Both of these extremes allow for too much subjectivity. The goal of the CLTS FS functional eligibility process is to be as objective as possible. When screeners are objective, the result is high "inter-rater reliability"--meaning that other screeners would choose the same answer as another screener. Each screener must gather as much information, objective data, as possible, and then ask, "Given all this information, what would other screeners choose for an answer?"
When meeting with a child and their family, asking questions, asking for demonstrations, and observing evidence carefully provides additional objective information. The screener can be curious, rather than critical, about the reasons people respond to the functional performance inquires with differing responses. A screener is often touching upon the emotions and needs of the child and family. Emotions and needs may affect an individual's perspective and therefore their answers. A certified screener with experience working with children and families must apply this awareness and interview expertise to assure an accurate CLTS FS result.
If further questions and observations don't indicate a clear answer for the CLTS FS, the screener should look for and consider additional information from health or school records plus other care givers or professionals
In summary, screeners should follow this three-step process:
- Ask more questions and rely on professional expertise in interview and observation. Ask the family or child for additional details or perhaps a demonstration of a skill. Consider the whole picture, to see if the "pieces" make sense.
- Seek additional information from other people such as the other parent, teachers, therapists, physicians and other people who interact with the child in a variety of settings.
- Ask, "Given all this information, what would other screeners choose for an answer?"
If still not clear, refer the question to State Clinical Staff.
B. Different Descriptions from Different People
Different people can describe a child's abilities, needs and problems very differently. This is expected due to varying perspectives among reporters, and because children often act differently in different settings or even with different people. Parents' perspectives and knowledge often are very different from that of a professional who sees the child only once a week. Children may in fact act very differently at school and at home. Adults' opinions, values, stresses, coping abilities and risk factors all affect how those adults describe a child's needs and behaviors. Cultural values and expectations can also create differences in how people perceive and describe a child.
The screener will consider all available information, such as health or school records. Then ask, "Given all this information, what would other screeners choose for an answer?"
During a screening, parent(s) may convey a wide variety of emotions and attitudes. The certified screener's role is to recognize and respond to those feelings and perceptions and to help describe a child's abilities as accurately and objectively as possible. The screener must be aware of the affects of stress, interpersonal relationships and family dynamics on a person's perception of a child's behaviors and needs. Professional opinions do not override parents. Rather a screener must address parents' views and engage with interest and questions that gently focus on objective information about the child. Here again is the three-step process to follow:
- Ask more questions and rely on professional observation. Ask for details, perhaps a demonstration. Consider the whole picture, to see if the "pieces" make sense.
- Seek additional information from other people such as the child's other parent, teachers, therapists, physicians and other professionals.
- Ask, "Given all this information, what would other screeners choose for an answer?"
C. Abilities Fluctuate
The CLTS FS is a functional eligibility tool; it is not a complete assessment of a child's current status. Screeners are allowed to add additional notes to serve as an assessment, but this is not the purpose or structure under which the CLTS FS was created or implemented. The CLTS FS is a broad baseline of information and it not formatted or constructed to serve as an individualized comprehensive assessment tool In addition, the screening tool addresses certain specific areas of skill and development relevant to functional eligibility criteria. It does not include many areas that would be included in assessment and service plan development activities. Therefore, if the screener is using the CLTS FS also as an assessment tool it may make it more difficult for the screener to choose the most accurate answer on the CLTS FS.
Responses to ADL/IADL, mental health and behavioral questions have different frequency requirements. These requirements are described in the instructions for those sections.
Remember that the screen is taken in total; even if some ADLs are not checked, the child could be eligible through different sections of the CLTS FS.
When screening a child who will be discharged within approximately one week from a skilled health care facility, for example a hospital, an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID), a State Center for Developmental Disabilities or an Institute for Mental Disorders (IMD), complete the screen based on how the child is expected to function upon their return home. This looking ahead is a normal part of discharge planning. If, for example, oxygen and intravenous (IV) will be stopped before the child goes home in two days, do not mark "IV" under treatment on the HRS portion of the screen. If the family is learning to do a two-person pivot transfer to prepare to use at home, indicate that the child needs assistance with transfers on the ADL portion of the screen, even if now the hospital does one-person transfers with a mechanical lift. The screener will need to gather additional information from facility staff and the child's parent(s) to get the most accurate picture of the child's needs at home, after discharge.
The screener must be able to envision the child at home. Therefore, the screener must have experience in community care for the target group being screened. The CLTS FS should be redone shortly after the child goes home, if the child's condition or situation changes from what was expected at the time the screen was initially completed.