LTCFS Instructions Module 2 - Long Term Care Functional Screen Target Groups

Glossary of Acronyms, P-01010 (PDF, 125 KB)LTCFS Paper Form, F-00366 (PDF, 145 KB)

Contents

Objectives

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

  • Describe the key components that constitute a "long-term care condition" in regard to the Long Term Care Functional Screen (LTCFS).
  • Define each target group as it relates to the LTCFS.

2.1 Long Term Care Functional Screen Target Groups

The LTCFS was designed to capture the needs of people who have a long-term care condition related to being a frail elder, having a physical or developmental disability, dementia (onset of any age), or a terminal condition. The length of time a person is expected to have a long-term care condition has a bearing on the program for which the person is eligible. In order for a person to be eligible for any home and community-based waiver (HCBW) program, the duration of the person’s long-term care condition is expected to last more than 12 months. In order for a person to be eligible for Family Care nursing home level of care (LOC) or non-nursing home LOC, his or her long-term care condition must be expected to last 90 days or more.

Conditions for Functional Eligibility:

  • The person must have a long-term care condition or have a condition that is expected to result in death within one year.
  • The person’s condition must meet one or more of the target group definitions that are eligible for publicly funded long-term care programs in Wisconsin. These eligible target groups are:
    • Frail elder
    • Physical disability
    • Intellectual/developmental disability per FEDERAL definition
    • Intellectual/developmental disability per STATE definition but NOT federal definition
    • Alzheimer’s disease or other irreversible dementia (onset any age)
    • A terminal condition with death expected within one year from the date of this screening
  • The person whose condition meets a target group definition must have a need for assistance from another person to complete activity of daily living/instrumental activity of daily living (ADL/IADL) or health-related services (HRS) tasks that are directly related to the conditions(s) that qualified the person for a target group.
  • Except for diagnoses of Alzheimer’s disease, other irreversible dementias, and terminal illness, a diagnosis alone is not sufficient to qualify an individual to meet a definition of any statutory target group.

General Guidance

A person will not meet a target group definition if he or she has a temporary physical, but not a long-term care condition. For example, a person who is otherwise healthy and independent breaks a bone. He/she is expected to make a full recovery but may need assistance; this is not a long-term care condition.

  • A person may meet a target group definition, but not be eligible for a Wisconsin long-term care program, if he or she does not have a need for assistance with ADL, IADL, or HRS tasks. For example, a person with mild cerebral palsy who is fully independent with everyday tasks is not eligible for Wisconsin’s publicly funded long-term care programs.
  • A person may need assistance with an ADL, IADL, or HRS task, but not be eligible for a long-term care program if he or she does not meet one of the eligible target group definitions. For example, a person with schizophrenia and no other condition would not be functionally eligible for a long-term care program in Wisconsin.
  • A person meeting only the “Severe and Persistent Mental Illness” (SPMI) target group definition will not be functionally eligible for a long-term care program in Wisconsin. The screener should still record the person’s need for assistance from another person related to the screened person’s SPMI.
  • A person meeting only the “None of the above—No Target Group” definition will not be functionally eligible for a long-term care program in Wisconsin.
  • A person may have a disability determination from the Social Security Administration and NOT meet a target group definition.

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2.2 Target Group Assignment

Any individual’s condition may meet the definitional requirements of more than one target group at a time. The LTCFS is designed to identify needs for individuals with conditions related to the following:

  • Frail elder
  • Physical disability
  • Intellectual/developmental disability per FEDERAL definition
  • Intellectual/developmental disability per STATE definition but NOT federal definition
  • Alzheimer’s disease or other irreversible dementia (onset any age)
  • A terminal condition with death expected within one year from the date of this screening
  • Severe and persistent mental illness
  • None of the above (no target group)

Applicable target groups are defined in state statute or administrative code. Refer to each target group definition for the reference.

Professional or Other Collateral Contacts
In some instances, a physician, psychiatrist, psychologist, or other health care provider will need to be consulted to obtain additional information to clarify an individual’s diagnosis or health condition. Refer to Module 4 of these instructions for direction as to how a diagnosis must be verified.

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2.3 Frail Elder Target Group

Frail elder means an individual aged 65 or older who has a physical disability, or an irreversible dementia, that restricts the individual's ability to perform normal daily tasks or that threatens the capacity of the individual to live independently. Wisconsin Admin. Code § DHS 10.13(25m).

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2.4 Physical Disability Target Group

Physical disability means a physical condition, including an anatomical loss or musculoskeletal, neurological, respiratory or cardiovascular impairment, which results from injury, disease or congenital disorder and which significantly interferes with or significantly limits at least one major life activity of a person." Wisconsin Stat. § 15.197(4)(a)2.

"Major life activity" means any of the following: A. Self-care. B. Performance of manual tasks unrelated to gainful employment. C. Walking, D. Receptive and expressive language, E. Breathing, F. Working, G. Participating in educational programs, H. Mobility, other than walking, I. Capacity for independent living." Wisconsin Stat. § 15.197(4)(a)1.

Physical Disability and Mental Health or Substance Use Issues
When a person has co-morbidity such as a mental health diagnosis with a substance use issue, he or she must have another medically or physically disabling condition in order to meet the physical disability target group definition. The screener must consider whether this other condition significantly impairs the functional abilities of the person being screened to a degree that this medically or physically disabling condition meets the statutory definition above.

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2.5 FEDERAL Definition of Intellectual/Developmental Disability

A person is considered to have an intellectual disability if he or she has: (i) A level of intellectual disability described in the American Association Intellectual and Developmental Disabilities' Manual on Classification in Intellectual Disability, or (ii) A related condition as defined by 42 C.F.R. § 435.1009 which states, "Person with related conditions" means individuals who have a severe, chronic disability that meets all of the following conditions:

(a) It is attributable to:

  1. Cerebral palsy or epilepsy or
  2. Any other condition, other than mental illness, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of intellectually disabled persons, and requires treatment or services similar to those required for these persons.

(b) It is manifested before the person reaches age 22

(c) It is likely to continue indefinitely

(d) It results in substantial functional limitations in three or more of the following areas of major life activity: self-care; understanding and use of language; learning; mobility; self-direction; or capacity for independent living.

If a person with an intellectual/developmental disability (I/DD) has no other health condition, he or she must meet the intellectual/developmental disability per federal definition target group definition in order to be eligible for the CIP 1A, CIP 1B, or the IRIS Medicaid waiver programs.

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2.6 STATE Definition of Developmental Disability

Developmental disability' means a disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader-Willi syndrome, intellectual disability, or another neurological condition closely related to an intellectual disability or requiring treatment similar to that required for individuals with an intellectual disability, which has continued or can be expected to continue indefinitely and constitutes a substantial handicap to the afflicted individual. 'Developmental disability' does not include senility which is primarily caused by the process of aging or the infirmities of aging. Wisconsin Stat. § 51.01(5)(a).

Wisconsin's definition of developmental disability is broader than the federal definition, in that it does not include the restrictive clauses “b” (onset before age 22) and “d” (substantial functional limitations) that are found within the federal definition.

If a person with an intellectual/developmental disability qualifies for a long-term care target group ONLY by meeting the definition of I/DD per state definition, he or she may be eligible for managed long-term care in Wisconsin, but will not be eligible for CIP 1A, CIP 1B, or the IRIS Medicaid waiver programs.

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2.7 Alzheimer's Disease or Other Irreversible Dementia Target Group

Dementia means Alzheimer's disease and other related irreversible dementias involving a degenerative disease of the central nervous system characterized especially by premature senile mental deterioration and also includes any other irreversible deterioration of intellectual faculties with concomitant emotional disturbance resulting from organic brain disorder. Wisconsin Stat. § 46.87(1)(a).

Statute does not limit organic brain disorder to the specific diagnosis “organic brain syndrome.”

Whether a person’s dementia is irreversible, it is not always discernible by diagnosis alone. For instance, alcoholic dementia or drug-induced dementia may or may not be reversible. A screener may need to consult with a health care provider to confirm whether the dementia experienced by a person being screened is irreversible.

The following is a list of some conditions with irreversible dementia:

  • Alzheimer’s disease
  • Creutzfeld-Jakob disease
  • Friedrich’s ataxia with dementia
  • Frontotemporal dementia
  • Huntington’s disease with dementia
  • Lewy body disease
  • Mixed dementia
  • Multi-infarct dementia
  • Parkinson’s disease with dementia
  • Pick’s disease
  • Progressive supranuclear palsy
  • Vascular dementia
  • Wernicke-Korsakoff syndrome
  • Neurocognitive disorder (NCD) or organic brain syndrome (OBS) due to an irreversible dementia

The following is a list of some conditions that may cause a reversible cognitive impairment. Consult with the person’s health care provider to verify whether the individual’s impairment is irreversible and is considered to be dementia:

  • Medication side effects
  • Depression
  • Hypothyroidism
  • Infection such as AIDS or syphilis
  • Vitamin B12 or folate deficiency
  • Excess use of alcohol

The preceding lists are not all-inclusive.

The diagnoses of mild cognitive impairment or cognitive impairment NOS are not irreversible dementia diagnoses. Refer to the Diagnoses Cue Sheet, P-00814 (Excel, 103 KB) to accurately complete the Diagnoses Table.

It may be difficult to differentiate between a person’s organic brain disorder and a mental illness or substance use issue he or she may be experiencing. In these instances, a screener may need to consult with a health care professional to verify the cause of the person’s dementia-like symptoms.

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2.8 Terminal Condition Target Group

For the purposes of the LTCFS, terminal condition is defined as a condition with which a person’s death is expected within one year from the date of the person’s screening.

The screener must select both “K3: Terminal Illness (prognosis less than or equal to 12 months)” on the LTCFS Diagnosis Table and the associated diagnosis that has created the terminal condition (such as “J2: Cancer in the past 5 years”). Written documentation from the physician of the person being screened that verifies the terminal nature of the condition is not required.

A screener should select “Yes” for the box on the LTCFS Additional Supports module that asks, “Is the condition related to the eligible target group expected to last more than 12 months OR does the person have a terminal illness?”

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2.9 Brain Injury Information

In most long-term care programs, traumatic brain injury is included with the physical disability target group, even if the resulting symptoms are only cognitive or behavioral.

A person with brain injury may meet the federal definition of I/DD if their injury occurred before age 22. If the brain injury occurred at age 22 or after, the person’s condition may meet the state definition of I/DD, but not the federal definition.

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2.10 Severe and Persistent Mental Illness Target Group

For the purposes of the LTCFS, severe and persistent mental illness (SPMI) is defined as a mental illness that is severe in degree and persistent in duration, which causes a substantially diminished level of functioning in the primary aspects of daily living and an inability to cope with the ordinary demands of life, which may lead to an inability to maintain stable adjustment and independent functioning without long-term treatment and support, and which may be of lifelong duration.

The diagnosis of SPMI encompasses a wide spectrum of psychotic and other severely disabling psychiatric diagnostic categories, but does not include organic mental disorders or a primary diagnosis of an alcohol or substance use issue.

For example, a person who is stable, functional, and treated with antidepressant medication on a short-term basis for situational, grief-related depression, would not meet this target group’s definitional requirements. Conversely, a person with a long-standing diagnosis of schizophrenia who refuses treatment, is frequently unstable and hospitalized, would meet this target group’s definitional requirements.

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2.11 Mental Illness and Substance Use Co-Morbidity

Although severe and persistent mental illness is included as a LTCFS target group, eligibility for Wisconsin’s publicly funded long-term care programs requires that consumers also have LTC conditions related to another primary LTC target group (such as frail elder, physical disability, intellectual/developmental disability). Severe and persistent mental illness cannot be the only LTC target group determined if a person is to be found eligible for publicly funded long-term care programs.

“Co-morbidity” means having more than one diagnosis; in this document, it refers to having a mental illness and/or substance use diagnosis along with physical disability, being a frail elder, or having an intellectual/developmental disability.

A person with mental health or substance use issues may be eligible for long-term care programs in Wisconsin if he or she meets the definition for at least one target group for publicly funded long-term care, and has functional limitations that are related to the condition that qualified the person for that target group.

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2.12 What If No Target Group Applies?

Applicable target group definitions are statutory in nature. Individuals who do not meet the definition of any adult LTC program target group, will not be found eligible by the functional screen application.

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Last Revised: January 13, 2017