- 1.1 History
- 1.2 The LTCFS Determines Eligibility for Long-Term Care Programs
- 1.3 Other Functions of the LTCFS
- 1.4 Requirements for Screener Qualifications
- 1.5 Requirements for Quality Assurance
- 1.6 The LTCFS Is Voluntary
- 1.7 Confidentiality
- 1.8 Screening and Re-Screening Requirements
- 1.9 The Screening Process
- 1.10 Reliability of Screen and Screeners
- 1.11 Screening Limitations and Strategies to Mitigate Limitations
- 1.12 Screening During Acute Episodes
- 1.13 Impending Discharge
- 1.14 Verifying Diagnoses and Health-Related Services
By the end of this module the screener should be able to:
- Explain the major criteria used to develop the LTCFS.
- Explain the purpose for the LTCFS.
- Explain how the LTCFS is to be administered, by whom, and in what manner.
- Utilize strategies for minimizing identified screen limitations.
- Document fluctuations in abilities and long-term care needs of people being screened.
- Recognize circumstances that require consultation with a medical professional to properly complete the health-related sections of the LTCFS.
The Wisconsin Adult Long Term Care Functional Screen (LTCFS) has been in use, in paper and electronic format, since 1997. The LTCFS describes the assistance a person needs with the following activities and conditions:
- Activities of Daily Living (ADLs): Bathing, dressing, mobility in-home, transfers, eating and toileting
- Instrumental Activities of Daily Living (IADLs): Meal preparation, medication administration and management, money management, telephone, transportation, and employment
- Health-Related Services Tasks (HRS): Including skilled nursing
- Memory and Cognition
The LTCFS also includes information related to mental health and substance use and the person’s preferred living arrangement.
The LTCFS web-based application (FSIA or Functional Screen Information Access) contains logic that interprets data to determine an adult’s nursing home level of care, intellectual/developmental disability level of care, and functional eligibility level for Wisconsin's long-term care programs. The long-term care (LTC) eligibility and nursing home level of care logic has been tested for reliability and validity, and approved by the Centers for Medicare and Medicaid Services to replace previous methods of Medicaid home and community-based waiver services functional eligibility in Wisconsin. The major advantages of the LTCFS are that eligibility determinations are issued upon completion of the LTCFS and reflect an objective method of eligibility determination.
The LTCFS is different from other screening tools such as the Minimum Data Set (MDS) completed in nursing homes and Outcome and Assessment Information Set (OASIS) tool used by home health agencies because it must meet the needs of Wisconsin's LTC programs. In particular, the LTCFS works for all three federal Medicaid target groups: frail elders with health conditions or dementia (mild or severe); adults with physical disabilities (some with health conditions); and people with developmental/intellectual disabilities with various cognitive functioning levels, behavior symptoms, and/or health conditions. The LTCFS functions to capture the needs of people living at home as well as those in substitute care settings such as group homes and adult family homes, or institutions, including nursing homes and intermediate care facilities for individuals with intellectual disabilities (ICF-IDDs). Other criteria used to develop the LTCFS include the following:
- Clarity: Screeners from a variety of professional disciplines must clearly understand definitions and answer choices.
- Objectivity and Reliability: The LTCFS is as objective as possible to attain highest possible "inter-rater reliability," i.e., two screeners should answer the same question in the same way for a given person. Subjectivity is minimized to ensure fair and proper eligibility determinations.
- Brevity: The LTCFS determines program functional eligibility. It serves as a baseline of information about the person. A more in-depth assessment is needed to develop a service plan that reflects the person's strengths, values, and preferences for long-term care services.
- Inclusiveness: The LTCFS accurately describe each person within the responses available.
The LTCFS determines functional eligibility for long-term care programs for persons who are frail elders, have physical disabilities, dementia, a terminal illness, or intellectual/developmental disabilities. A person must be 18 years of age or older to participate in a publicly funded long-term care program for which the LTCFS determines eligibility. These programs are the Community Options Program (COP); COP Waiver (COP-W); Community Integration Program 1A/1B (CIP 1A/1B); Community Integration Program II (CIP II); Include, Respect, I Self-Direct (IRIS); Family Care; Family Care Partnership; and the Program of All-Inclusive Care for the Elderly (PACE). Early screening is available for persons aged 17 years 6 months or older to assist planning for transition to the adult long-term care system.
Once a screener completes an applicant's LTCFS, the eligibility logic built into the web-based application determines the person’s level of care and functional eligibility for Wisconsin’s adult long-term care programs. Wisconsin has the following four nursing home levels of care (for adults with physical disabilities and frail elders):
- Intermediate Care Facility, level 2 (ICF-2)—Lowest needs
- ICF level 1 (ICF-1)—Moderate needs
- Skilled Nursing Facility (SNF)—High needs
- Intensive Skilled Nursing Services (ISN)—Highest needs
Wisconsin has four institutional levels of care for people with intellectual/developmental disabilities (DD):
- DD1A—People with significant medical problems in addition to cognitive disabilities
- DD1B—People with significant behavioral problems in addition to cognitive disabilities
- DD2—People who have a cognitive disability and are neither DD1A nor DD1B level of care and who need help with all or most ADLs and IADLs
- DD3—People who have a cognitive disability and who are more independent with most ADLs and IADLs
Note: People with intellectual/developmental disabilities who meet certain criteria for No Active Treatment (NAT) may qualify to be served by a waiver program for people with physical disabilities or a waiver program for people with frailties of aging. (See Module 11.9, No Active Treatment.)
Level of Care in Medicaid Home and Community-Based Services Waiver Programs:
In general, Wisconsin's federally approved Medicaid home and community-based services long-term care programs require that the applicant achieve a qualifying nursing home (NH) or intellectual/developmental disability (I/DD) level of care on the LTCFS, as described above. People who do not meet a qualifying level of care may still be eligible for long-term care under COP Level 3 or a more limited Family Care Non-Nursing Home level of care benefit.
Level of care and functional eligibility criteria interact as eligibility is determined. For example, applicants who have shorter-term needs (more than 90 days, but less than one year) may still achieve a nursing home level of care. However, these people will not be eligible for the CIP 1A/1B, CIP II, IRIS, or COP-Waiver programs. These applicants may be eligible for the Family Care program at a nursing home or non-nursing home level of care.
The remainder of this section describes NH and I/DD level of care (LOC) and how these interact with Family Care eligibility.
NH or DD Level of Care and Family Care:
To qualify for nursing home or DD level of care, a person must have a long-term care condition likely to last more than 90 days.
The NH and DD levels of care interact with the two levels of Family Care eligibility. The two levels of Family Care eligibility are "Family Care Nursing Home LOC" and "Family Care Non-Nursing Home LOC."
- Family Care Nursing Home LOC: Family Care nursing home LOC includes all three nursing home levels of care and all four DD levels of care. If a person receives a NH or IDD level of care, they are eligible at the Family Care nursing home LOC.
- Family Care Non-Nursing Home LOC: People at the Family Care non-nursing home LOC usually need help with only one or a few ADLs or IADLs and do not have a nursing home LOC or DD LOC. Only those people at the Family Care non-nursing home LOC who are financially eligible for Medicaid are entitled to the limited non-nursing home benefit package.
Screeners should confirm all health-related services with a nurse or other health care professional familiar with the person. When unsure about whether someone meets the level of care, screeners should consult with their agency’s screen liaison, who can contact the Department of Health Services (DHS), if necessary.
- Serves as a foundation for the comprehensive assessment performed by the long-term care program selected by a person.
- Provides data for quality assurance and improvement studies for DHS and long-term care programs utilizing the LTCFS, including identifying cases for targeted reviews.
- Indicates the need for referrals to adult protective services, mental health services, substance use services, or other community resources.
- Provides actuarial information for rate setting and monthly allocations within some long-term care programs.
The LTCFS determines Medicaid waiver program functional eligibility. Therefore, screeners must meet specific qualifications that ensure knowledge of long-term care needs in order to ensure reliable screening and consistent LTCFS administration.
All people administering the LTCFS must meet the following four requirements:
- Meet the minimum criteria for education and experience, which are:
- Bachelor of Arts or Science degree, preferably in a health or human services related field, and at least one year of experience working with at least one of the target populations (frail elder, physical disability, or intellectual/developmental disability); or
- In home and community-based waiver agencies, those screening people with intellectual/developmental disabilities must be qualified as QIDPs.¹
- Meet all training requirements as specified by DHS:
- Completion of the web-based clinical certification course. This course is currently the primary way to meet the DHS training requirements.
- Have at least one year of experience working in a professional capacity with long-term care consumers.
- Successfully complete all mandatory certification courses, exams, refresher courses, and continuing skills testing as required by DHS.
Each screening agency must identify a liaison to DHS in regard to screening activities performed by the agency. The duties and responsibilities of this person are defined in contracts between DHS and screening agencies.
¹ Qualified Intellectual Disabilities Professional (QIDP) means a person who has specialized training in intellectual disability or at least one year of experience treating or working with persons with intellectual disability and is one of the following:
- A psychologist licensed under Wis. Stat. ch. 455;
- A physician;
- A social worker with a bachelor's degree or graduate degree from a school of social work accredited or approved by the Council on Social Work Education;
- A physical or occupational therapist who meets the requirements of Wis. Admin. Code §§ DHS 105.27 or 105.28;
- A speech pathologist or audiologist who meets the requirements of Wis. Admin. Code §§ DHS 105.30 or 105.31;
- A registered nurse;
- A therapeutic recreation specialist who is a graduate of an accredited program who has a bachelor's degree in a specialty area such as art, dance, music, physical education, or recreation therapy; or
- A human service professional who has a bachelor's degree in a human services field other than those noted under 1-7, such as rehabilitation counseling, special education, or sociology.
There are quality performance and assurance requirements in addition to the qualifications, training, and certification requirements for screeners in section 1.4. These promote the consistency and accuracy of administration of the screen by screening agencies. There are three components of functional screen quality assurance.
- LTCFS quality assurance efforts begin with each screener. It is the screener's responsibility to be an objective screener, to be informed of the instructions, and to corroborate information gathered from the person and collateral contacts. If a screener has questions, these should be addressed by the person designated as the screen liaison in each screening agency. The LTCFS results issue a determination of functional eligibility for Medicaid waiver programs. Therefore, screeners should be aware that unethical or fraudulent performance of screening activity will be referred to the DHS Office of the Inspector General for investigation.
- Part of the screen liaison's role is to oversee quality assurance activities related to the LTCFS. At a minimum, each agency must include the following strategies:
- Ensure completion of continued skills testing by all certified screeners.
- Train, mentor, and monitor both new and experienced screeners.
- Perform random sampling for accuracy and consistency of screens performed by each screener at the agency.
- Complete reports as requested by DHS.
- Consult with the DHS LTCFS staff about complicated screens or to clarify policy and procedure.
- Discontinue access to FSIA for any screener whose job duties or employment status has changed.
- Respond to quality assurance findings of DHS.
- DHS performs continuous monitoring of screener performance, screen accuracy and completeness, and appropriate use of the web-based screen application by staff at all screening agencies. Screening agencies will be required to perform corrective action to improve or remediate DHS findings.
Consumers, or their legal guardians, must consent to having the LTCFS completed in order to enroll in a long-term care program (COP, CIP, IRIS, Family Care, or PACE/Partnership). The LTCFS should not be completed without the consent of the person being screened or their legal guardian.
Screening agencies must comply with confidentiality rules and requirements and must obtain a signed release of information from the person being screened, or their legal guardian, where applicable, to collect medical records, educational records, and other records needed to complete the screening process. Signed releases of information must be retained in the person’s case record.
All information collected for the LTCFS or during the screening process is confidential. It is to be treated following the same requirements for confidentiality as other long-standing screens and assessments that contain personally identifying health information.
When an aging and disability resource center (ADRC) refers a person for enrollment in a long-term care program, the person’s functional screen may be shared with that program without separate written authorization. Long-term care programs do not need written permission to refer people to an ADRC. Each ADRC has access to view the functional screen in FSIA for any person served by a long-term care program that operates within the coverage area of the ADRC.
However, release of a functional screen to another long-term care program, another person, or any other entity requires written authorization by the person screened, or their legal guardian when appropriate.
An initial LTCFS is required in order to establish level of care and functional eligibility for all publicly funded long-term care programs serving adults in Wisconsin. An annual screen is required thereafter to determine continued level of care functional eligibility.
If an IRIS participant requests a budget amendment to increase their IRIS budget allocation by 25% or more to cover care-related expenses, then the participant must undergo a re-screen before consideration of the request. ADRCs provide counseling to long-term care consumers and their families about all long-term care options, regardless of whether consumers need public assistance to pay for services or can pay privately. The ADRC is the initial screen agency for people seeking publicly funded long-term supports.
ADRCs provide information and assistance, early intervention and prevention, urgent services, and inform the public about community resources within the LTC system and within the community. The multifaceted nature of ADRCs is beneficial to consumers, since they are able to get information on all long-term care eligibility and options.
The LTCFS is also administered by long-term care program staff at managed care organizations (MCOs), county waiver agencies, and IRIS consultant agencies as part of their program activity, and for annual functional eligibility determinations. However, long-term care programs may not be involved with performing the LTCFS or performing pre-screening for a person prior to that person’s enrollment in the long-term care program.
If a person enrolled in a LTC program experiences a substantial change of condition, then the person must be rescreened to determine if the change in condition impacts the person’s level of care.
The following are examples of changes of condition when re-screening is necessary:
- Larry, an 88-year-old program participant, has a stroke.
- Mary, a 79-year-old woman, regains her mobility after recovering from a hip fracture.
- Jose, a 44-year-old man with Down syndrome, is diagnosed with early onset dementia.
When re-screening is performed, it is important that the screener review the person's previous screens for information and historical perspective. Functional eligibility may be calculated more often than annually, based on change in the condition of the person being screened or when requested.
The screener must document the nature of a change in condition in the Notes sections on the web-based LTCFS. Effective use of notes assists the screening agency and DHS to assess the completeness and accuracy of screens and reduces the number of requests for information made by DHS during screen reviews. Finally, thorough notes assist the screening agency, DHS, and Division of Hearings and Appeals to understand the actions taken by a screening agency, should an administrative hearing appeal be filed.
The screening process requires face-to-face contact with the person being screened. The LTCFS—initial, annual, or re-screen—must be completed based upon a meeting with the person, even if the person is unable to communicate.
The Interview Process
The LTCFS tool captures relevant information. It is not an interview tool. Screeners are expected to use professional skills to interview the person and assess the situation. Completion of the modules of the web-based LTCFS may occur in any order. It may take more than one contact with the person to complete the screen. The face-to-face interview may take place in any setting that is familiar to the person being screened, including, but not limited to, the person’s residence, a substitute care setting such as a community-based residential facility (CBRF), or at a hospital or nursing home. However, best practice is to perform the interview with the person and their family or collateral contacts in the person’s residence. This allows for discussion in a private setting and also allows the screener to observe the person in their natural environment.
Screeners should use their professional interview skills to gather information in a way that is appropriate for a given person. The screener will need to ask questions in a variety of ways, use communication strategies that best meet the needs of the person being interviewed, and use collateral contacts for additional information, as necessary. Collateral contacts include family, significant others, formal or informal caregivers, health care providers, and agencies serving the person.
The screening interview requires the screener to ask probing questions of a very personal nature. The screener must use tact and sensitivity to obtain honest and complete responses. Often, use of open-ended questions will result in the discovery of information that very specific questions will not uncover. Screeners must often look for visual clues, facial expressions, and interactions between the person and their significant others that may indicate undisclosed needs. A tour of the person’s home and direct observation of the person as they perform everyday activities is helpful, especially when there appears to be a discrepancy between the person’s report and the activities they perform.
When using translators or interpreters during a screening interview, ensure they understand that a Medicaid functional eligibility determination is being made and that they must not have a personal interest in the outcome of the determination. When relying on the person, family, friends, or caregivers to provide information during a screen interview, make them aware of the nature of the screen and inform them that coaching of responses or other activities that may result in an inaccurate portrayal of the needs of the person being screened, are not allowed. Refer instances of alleged Medicaid fraud to the DHS Office of the Inspector General at 877-865-3432.
The LTCFS has statistically acceptable levels of validity and reliability. However, it is generally recognized that any objective rating of the functioning, cognition, behavior, and symptoms of unique people can be difficult. This difficulty calls for a high level of vigilance by screeners to ensure the greatest possible accuracy in the LTCFS.
Screeners must adhere to the following guidelines:
- Read and follow screen definitions and instructions closely. The LTCFS Instructions document is reviewed and revised on a regular basis to improve the clarity of instructions and reflect the findings of the DHS quality monitoring activities.
- Make screen selections thoughtfully and carefully to ensure accuracy.
- Select the answer that most accurately describes the person’s needs. This response must not be influenced by factors such as cost of care that are not factors in determining the person’s level of care.
Refer all questions to your designated screen liaison. The screen liaison will refer unresolved questions to DHS. This process assures that interpretations are consistent and communicated to all agencies utilizing the LTCFS. Revisions will be made to the LTCFS, as deemed necessary by DHS.
The following limitations have been identified in national studies to be characteristic of screening tools similar to the LTCFS:
- Health care and institutional providers tend to overrate the person's dependency on others.
- Guardians, spouses, and family members often tend to overrate the person’s dependency on others.
- People often underrate their need for help from others and tends to overrate their abilities.
- People’s functional abilities may fluctuate, making it difficult to select a "best" answer.
- People may provide conflicting information at different times or to different screeners.
- Screen selections may vary depending on the screener’s experience with the person.
- Screen selections may vary depending on the profession of the screener.
- Some subjectivity may remain even with questions and processes designed to promote objectivity.
The following sections guide LTCFS screeners on strategies to mitigate these potential limitations.
Conflicting Information from Different People
Screeners may get different information about people being screened from different sources. People may function less independently in day care facilities or institutional settings than they do at home. Staff at such facilities may tend to perceive more dependency than family or peers in the community perceive. Screeners must use professional judgment to describe the person's functional abilities as accurately as possible using the information from multiple sources. A good source of information, in addition to the person, is someone who does a lot of direct care for the person and with whom the person has a positive relationship. In a health care facility, the screener should talk to a nurses' aide in addition to the nurses. In the home, a personal care worker might provide a more accurate description than family members.
Person Gives Apparently Inaccurate Information
The statements made by a person about their abilities may not be consistent with needs and activity that are directly observed by the screener or those reported by others. If this occurs, then the screener will follow this four-step process:
- Seek more details from the person being screened.
- Seek additional information from collateral contacts.
- If possible, ask the person to demonstrate tasks such as getting into and out of the bathtub.
- Use professional judgment to make the most accurate selections while following the definitions and instructions for the LTCFS.
The goal is for the LTCFS screener to be as objective as possible, and to have high "inter-rater reliability"—meaning that other screeners would make the same selection on the person’s LTCFS. For this reason, the screener’s selections on the LTCFS must be based on as much objective information as possible. Objective information can be obtained by asking questions, asking for demonstrations, and observing evidence carefully. If selecting the appropriate response is still challenging, then discuss the concerns with the agency screen liaison, who can assist in marking the screen appropriately or request guidance from DHS. The screener should include detailed notes to explain the selections made on the LTCFS in these circumstances. For example, if a person who can barely walk and transfer himself tells you he bathes himself, but his poor hygiene indicates otherwise, then the screener would follow these steps:
- Seek more details: Ask him how he bathes (for example, in the bathtub, the shower, or a sponge bath). Ask to look at his bathroom to check for accessibility and adaptive equipment. Ask him how he gets in and out of his bathtub. If it has high sides, then ask him if he can lift his foot that high, and to show you.
- Seek information from collateral contacts: Ask him if you can talk with his family members. They may have opinions ("He should be in a nursing home") as well as objective information ("He's really gone downhill since mom died last year, he's fallen at least four times, he can barely move, he hasn't been in that bathtub for months, he won't accept any help from us even when we tell him he needs a bath.").
- Use your professional judgment to select the best answer: In this example, it seems he's definitely not independent with bathing. It's not exactly clear whether Bathing Level of Help #1 (helper does not have to be present throughout task) or #2 (helper does have to be present throughout task) is most accurate. With the history of recent falls and his excessive independence, #2 might more accurately reflect what he really needs at this time.
Some screens or data collection instruments such as the MDS, required of nursing homes, and the OASIS, required of home health agencies, are designed to provide a "snapshot" view of a person’s functional status. These tools assess functioning in the past seven days or over the past month. The LTCFS allows for a broader timeline in order to more accurately reflect a person’s long-term care needs. Many long-term care participants have conditions and abilities that fluctuate over time. The screener will make the best selections possible on the LTCFS when addressing fluctuating needs. When completing the screen, use the following guidelines:
- If the person's functional abilities vary over months or years, then make selections that are closest to the average frequency of help needed.
- If the person's functional abilities vary day-to-day, then make selections that most accurately describe his/her needs on a "bad" day.
- If the person's functional abilities vary week-to-week, make selections that reflect the staff needed to meet the person’s need for assistance to maintain the person’s health and safety.
An acute episode involves conditions or circumstances regarding the person’s health or ability that are expected to resolve in the next few weeks. Acute episodes may occur at home, in the hospital, in a nursing home, or in other locations.
The LTCFS may be completed when people enter nursing homes or residential facilities. It is expected, then, that some LTCFS responses will reflect higher needs due to acute episodes and conditions, and that the person’s condition may improve over the days, weeks, or months following an acute episode. The person’s improved condition will be evident in their next annual LTCFS. However, if a person experiences a change in condition that is likely to affect their eligibility, then a re-screen must be performed when the change in condition is observed.
If a screener performs a LTCFS for a person who is preparing for discharge from a skilled health care facility, then the screener completes the LTCFS based on the person’s capacity for self-care and the supports and services that are anticipated to be needed when the person returns home. The discharge planning process anticipates the person’s function when they arrive home and in order to determine the supports and services the person will require.
For example, if the person was using oxygen and intravenous (IV) medication in a nursing home, but these treatments will be ended before the person returns home, then the screener will not make selections for these treatments on the Health-Related Services section of the LTCFS. If a person is using a mechanical lift in a hospital, but family members are learning to perform a two-person pivot transfer for use in the home, then no equipment for lifting should be selected on the LTCFS. The screener will review the discharge plan and talk with facility staff, family, and others to get the most accurate picture of the person's needs at home, after discharge.
The screener must be able to envision the person at home, based upon the screener’s experience in community care.
The Health-Related Services (HRS) table of the LTCFS is important in determining a person's level of care and program eligibility. The HRS table collects data that is used to determine whether the person meets an eligible level of care. Screeners must verify health-related information, diagnoses, and health-related services for the LTCFS. Screeners will need to contact a health care provider to obtain accurate information on health-related services and diagnoses.