8.1 Overview of the Health-Related Services (HRS) Table
8.2 Medical or Skilled Nursing Needs (PDF)
8.3 Definitions for Particular Health-Related Services (PDF)
8.4 Frequency of Help/Services Needed
8.5 Expected to last, at this frequency, and child is not expected to become independent at this task for at least six months or more?
- The HRS Table assigns "weights" to each checkbox in complex ways.
- There are many ways to get a level of care (LOC); even though one task for a child is not on the table or the screener cannot check it, the child may get an LOC some other way.
- The screen logic can "see" if a child is unable to report problems and for some HRS tasks will assign heavier "weights" for that child. For example, a tracheostomy in a baby requires much more oversight than a tracheostomy in a healthy teenager who can report problems and get help if needed.
- Medications (except for intravenous ones) are absent from the HRS section. Of course giving and monitoring medications are very important, often life-saving, tasks for children. Because these tasks are almost universally done for all children, they are not helpful in distinguishing nursing-home eligible children from noneligible ones. It is difficult to remove subjectivity between "important," "dangerous," "life-saving" medications from "routine" ones, and the line cannot be drawn between routes of administration.
- Similar issues arose with other tasks that may or may not make a child eligible. For example, therapies, therapy follow-through exercises, and wound and special skin care. They usually do not in themselves make a child hospital or nursing home eligible. At times they can be so extensive and time-consuming that they would make a child hospital or nursing home eligible. For now, the CLTS FS uses number of times per day as the objective criteria.
In summary, the HRS Table information may be partially addressed in another portion of the screen such as ADLs/IADLs where a screener feels they cannot fully describe a child. That is because the goal is to seek accurate results with the briefest possible screen. Information that could not objectively determine LOC was left out. Remember that responses to all questions on the functional screen for a child will be assessed in total when calculating functional eligibility.
Two children could have the same skilled nursing needs, but one might get a Nursing Home LOC and one not. That is because one did not have the functional impairments that are needed to be considered nursing home eligible.
Also, two children could have the same skilled nursing needs, but only one is expected to have those needs long term (for more than six more months). The child with similar needs that are not expected to persist would not be eligible for long-term support programs.
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Detailed instructions for 8.2 Medical or Skilled Nursing Needs PDF)
Detailed instructions for 8.3 Definitions for Particular Health-Related Services (PDF)
- For each condition or task (each row) that applies to the child, the screener will check to indicate either that the child is independent with the task, or that they need skilled nursing help from others.
- If the child does need skilled nursing help from others, screeners must indicate the frequency at which that help is needed.
Precision is important, and screeners will need to consult with healthcare providers or other experts familiar with the child and his or her needs.
Child is INDEPENDENT in Managing a Health-Related Service
A child is independent in turning the oxygen on and off, taking it on and off, checking their oxygen saturation level (if required), and changing water bottles and tubing (if required).
School nurse oversees the child's self-injections due to school policy, but the child is completely independent with the task and with monitoring for problems.
Ø The child knows how to check their own blood sugars but usually will not unless an adult reminds them and watches to make sure they do it.
If the child is not independent in managing a condition, place one checkmark in the column showing the most accurate frequency of "Skilled Nursing Help from Others."
Skilled Nursing Help from Others
The HRS Table looks for "Skilled Nursing Help from Others." "Skilled nursing" describes the task being done but not who is doing it. Parents and other family members or school professionals are often taught to do highly skilled nursing tasks.
Some examples of situations where parents and others are trained to provide this type of care include a mom managing a child's ventilator, a dad administering a child's IM (intramuscular) shots, and a nurse's aide, school aide, or other direct care workers having been taught to do the skilled task for this child. The screen is not concerned about someone doing other "unskilled" tasks not precisely listed on the functional screen. Skilled nursing help includes step-by-step cueing.
Frequencies of Skilled Nursing Help
The column headings are:
- 1 to 3 times/month
- 1 to 3 times/week
- 4 to 7 times/week
- 2 or more times a day
Indicate Frequency of Skilled TASKS, Not Duration of Condition
For conditions that are continually present (such as an indwelling urinary catheter), the checkmark should indicate the frequency of tasks related to the condition. When one condition involves more than one task, check the most frequent task with which help is needed from others. Oxygen is often worn continually; screeners should find the frequency at which the child needs help from others with particular tasks related to the oxygen.
Example: Sara has an indwelling urinary ("Foley") catheter in continually. The catheter is changed (by a nurse) every 30 days. Daily "cath care" is just soap and water as normal part of bathing and is not really considered a "health-related service" on the screen. No irrigations are needed. Sara also has a tracheostomy. Tasks related to this include having a nurse change the trach tube once every month, and a parent clean the trach site ("trach care") twice a day. The screener places two checkmarks: 1) Urinary catheter-related skilled tasks at "1 to 3 times/month" and 2) Tracheostomy Care at "1-2 times/day."
Because it is a screen for long-term supports, the screen cannot just take a "snapshot" of what the child is getting for treatments today or this week, unless those treatments are expected to last for months at that frequency.
The screener will encounter frequencies of treatments that do not fit the columns in this table. Options are limited for brevity. Here are some guidelines for rounding off or taking averages for differing frequencies:
- If the frequency of treatments varies over weeks or months, select the answer that seems closest to the average frequency of help needed.
- If the frequency of treatments varies day to day, select the answer that most accurately describes their needs on the higher frequency days.
- If something is done less than once every month, the screener will not check it on the HRS table. If a task is done "every month or two," ask how many times over the past six or 12 months. If that averages to almost once a month, check the "1 to 3 times/month" column.
- If the frequency of treatments averages to less than once a month, do not check it.
Multiple Frequencies of One Health-Related Service
There are often multiple frequencies for a single health-related service. As a rule of thumb, check the one with the highest frequency. For example, there will often be several skilled tasks for one IV, each at a different frequency. Check the one of highest frequency.
If the child is expecting to encounter health-related services in the near future, it may be difficult to determine the average frequency of help or services needed. With some conditions an educated estimate can be made. For example, if a child is expected to get a central line very soon it might be hard to predict the frequency of skilled tasks. However, since most central lines need to be flushed once a day, that is a safe box to check.
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A child must need long-term support, not just short-term. Sometimes the duration of a child's health-related needs may be challenging for screeners to discover. Health care professionals routinely make predictions about health conditions and treatments and their expected duration. Hopefully they have explained this to the parents or it is documented somewhere.
Check "No" if:
- Child is likely to be independent with the task within the next six months.
- Child is going to need less assistance (changing to a different frequency of intervention) with that task.
- Child is expected to have surgery soon and to fully recover within several weeks after that.
- Child is in intensive care now but is expected to recover within a few weeks or months.
- Child is in a total body cast but it is expected to be removed and activity resumed in about three months.
- Child has a temporary ostomy that is expected to be repaired within three months.
Check "Yes" if:
- The child currently has a tracheostomy, central line, TPN or is on a ventilator, which is expected to be removed in less than six months. The screener is to give the benefit of the doubt in case it takes longer than expected to wean the child from these life-sustaining treatments.
- Child is waiting for an organ transplant.
- Child is receiving physical therapy, occupational therapy, and speech therapy through the school system, and the IEP indicates the therapy will continue next year.