LTCFS Instructions Module 6 - Additional Supports

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:

  • Identify and correctly enter primary and secondary diagnoses that cause any need identified in this module.
  • Identify and correctly enter an individual’s need for overnight care or overnight supervision.
  • Identify and correctly enter whether an individual is participating in educational activity or employment.
  • Identify whether an individual has a legal guardian.
  • Determine and record the expected duration of long-term care conditions.
  • Identify whether a disability determination has been made by the Social Security Administration..

6.1 Introduction

This section describes additional supports that may be received by individuals who are being screened for eligible long-term care services.

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6.2 Identifying Primary and Secondary Diagnoses

For each need or additional support identified in this section, the diagnoses that cause the need or necessary support must be selected from options prepopulated in a drop-down menu. Only diagnoses that were previously identified on the Diagnoses Table will be prepopulated in the drop-down menus. These diagnoses will be used by FSIA to build the correct target group assignment for each individual that is being screened.

In regard to assignment of target group by FSIA, primary and secondary diagnoses carry equal weight. A primary diagnosis must be identified for each need or support identified in FSIA. A secondary diagnosis is not mandatory for each need or support that is identified. When a secondary diagnosis is not identified, the screener must select “None” from the drop-down menu that appears after each need or support that is identified.

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6.3 Overnight Care or Overnight Supervision

To select a need for “Overnight Care or Overnight Supervision,” the individual must have a physical, cognitive, or memory loss impairment limiting their ability to independently complete overnight care tasks or that require overnight care or overnight supervision.

Overnight care is defined as the need for hands-on assistance or verbal cuing from another person, to complete an ADL or health-related services task, during the overnight hours.

Overnight supervision is defined as the need for someone to be present to prevent, oversee, manage, direct, or respond to a person’s disruptive, risky, or harmful behaviors, during the overnight hours. Overnight supervision is indicated for a person unable to respond appropriately in an emergency (e.g., a vulnerable adult).

Overnight supervision is not indicated for a person without a physical, cognitive, or memory loss impairment who is uneasy being alone at night.

All people currently residing in ICF-IIDs, nursing homes, or residential care facilities DO NOT necessarily require overnight care or overnight supervision. You should ask yourself, "Would this person require overnight care or overnight supervision were the person not residing in an institutional or residential care facility?" Ask the facility’s staff whether the person being screened has ever demonstrated a need for assistance during the night shift. Does the person need to use the call button for staff at night? Or rather, does the person independently get to and from the bathroom at night?

REMINDER: Although licensed facilities have policies that require staff to monitor the residents at night, overnight care or overnight supervision is not necessarily needed by each resident.

OVERNIGHT CARE or OVERNIGHT SUPERVISION RATING SYSTEM

  • 0: No
  • 1: Yes; caregiver can get at least 6 hours of uninterrupted sleep per night
  • 2: Yes; caregiver cannot get at least 6 hours of uninterrupted sleep per night

Check this for a person who:

  • Needs help overnight from another person due to a physical or cognitive limitation jeopardizing their health and safety during that time.
  • Competently chooses to be alone overnight, although the person has a physical limitation typically requiring overnight care or overnight supervision (e.g., a need for assistance with transfers). Although the person is competently refusing the care or supervision, the need for the assistance still exists.
  • Has limited cognitive abilities and needs overnight supervision, although the person does not need overnight care.
  • Has disruptive or risky nighttime behavior that requires intervention.
  • Has an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months that require standby assistance. Standby assistance for seizure is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event they experiences a seizure.
  • Lives independently without assistance during the daytime, but requires intervention or supervision during the nighttime due to an unstable mental health condition (e.g., posttraumatic stress disorder).
  • Can safely get through a day without needing a cue or reminder, is able to make safe routine decisions, but does not have the cognitive capacity to know when to call for help and requires assistance in an emergency such as a flood, fire, or tornado.
  • Has a monitoring system with an onsite or offsite response person, and in the last six months the system’s intervention was initiated in response to a need at least once (e.g., WanderGuard or sound response system).
  • Has a need for a room-to-room monitor, bed alarm, or door alarm system with an onsite or offsite response person.
  • Has a Personal Emergency Response System (PERS) and uses it during the nighttime hours to summon assistance with a physical care need.

Do NOT check this for a person who:

  • Does not have a physical or cognitive limitation jeopardizing their health and safety overnight.
  • Desires overnight care or overnight supervision based solely on an age, gender, or cultural norm.
  • Receives overnight care or overnight supervision, but does not have an identified physical or cognitive limitation requiring that care or supervision. For example, a family member is uncomfortable with the person being alone at night, the person’s roommate requires overnight care or overnight supervision, or the person is up during the nighttime hours without a need for care or supervision.
  • Has a PERS and only uses it as a means of accessing assistance in the event of an emergency. The presence of a PERS alone does not by itself indicate a need for overnight care or overnight supervision.
  • Has a seizure disorder with no seizures in the last three months and there is no intervention needed; however, family or staff is present “just in case.”
  • Has a cognitive impairment without a physical limitation and can safely get through a day without needing a cue or reminder. Additionally, the person is able to make safe routine decisions and has the cognitive capacity to know when to call for help, and only requires assistance in an emergency such as a flood, fire, or tornado.
  • Has a cognitive impairment and a safety plan that they can articulate, which indicates they know how to respond appropriately in the event of an emergency.
  • Has a specific diagnosis. A need for overnight care or overnight supervision is not based solely on the person’s diagnosis.
  • Lives in a residential care setting, ICF-IID, or nursing home where overnight care or overnight supervision are provided based on facility policy and the person does not have an assessed need for those services.
  • Lives in a residential care setting with “sleep staff,” which refers to staff able to get at least six hours of uninterrupted sleep per night, although the person does not need overnight care or overnight supervision.
  • Lives in a residential care setting with “awake staff,” which refers to staff unable to get at least six hours of uninterrupted sleep per night, although the person does not need overnight care or overnight supervision.
  • For a person with a cognitive impairment, has a monitoring system with an onsite or offsite response person, and in the last six months the system’s intervention was NOT initiated.
  • Needs monitoring overnight related to their use of the internet.

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6.4 Employment

This section concerns the need for assistance to perform employment-specific activities (job duties). Since a person’s need for help with ADLs and other IADLs (e.g., transportation, personal care) is captured in other sections of the LTCFS, this section essentially concerns supports necessary for successful performance of work tasks.

Screener should clearly inform the person being screened that responses to the employment questions will not detract from the person’s eligibility for Social Security, Medicaid, long-term care, or other benefits.

EMPLOYMENT RATING SYSTEM

A. Current Employment:

  • 1: Retired (does not include people under 65 who stopped working for health or disability reasons)
  • 2: Not working (No paid work)
  • 3: Working full time (Paid work averaging 30 or more hours per week)
  • 4: Working part-time (Paid work averaging fewer than 30 hours per week)

B. If Employed, Where:

  • 1: Paid work where the environment and the work tasks are designed for people with disabilities (e.g., sheltered workshop)
  • 2: Paid work in other group situation for people with disabilities (e.g., work crew/enclave)
  • 3: Paid work outside the home (situations other than those described in B1 and B2)
  • 4: Paid work at home

C. Need for Assistance to Work (mandatory for ages 18-64; otherwise optional):

  • 0: Independent (with assistive devices if uses them)
  • 1: Needs help weekly or less (e.g., if a problem arises)
  • 2: Needs help every day, but does not need the continuous presence of another person
  • 3: Needs the continuous presence of another person
  • 4: Not applicable (please explain)

A. Current Employment Status
Choose one option that best describes the individual's status:

1: Retired (does not include people under 65 who stopped working for health or disability reasons).

Check this for a person who:

  • Is age 65 or older and is not in the workforce (whether receiving retirement benefits or not).
  • s under age 65, receiving retirement benefits, and did not stop working because of a health problem or a disability.

Do NOT check this for a person who:

  • Stopped working before age 65 due to a health problem or a disability, even if the person describes it as an “early retirement.” Instead, check “2: Not working (No paid work).”
  • Is involved in unpaid pre-vocational activities only. Instead, check “2: Not working (No paid work).”

2: Not working (No paid work).

Check this for a person who:

  • Is under age 65 and is not working for pay for any reason (unless retired).
  • Is under age 65 and stopped working due to a health problem or a disability.
  • Is involved in unpaid pre-vocational activities.
  • Is involved in volunteer activities, including volunteer and in-kind work to meet Medicaid Purchase Plan (MAPP) eligibility requirements.

Do NOT check this for a person who:

  • Is over age 65 and is not working for pay. Instead, check “1: Retired (Does not include people under 65 who stopped working for health or disability reasons).”

3: Working full time (Paid work averaging 30 or more hours per week)

Check this for a person who:

  • Is earning income for working, on average, 30 hours per week or more.
  • Is earning income at facility-based employment, on average, 30 hours per week or more. This includes pre-vocational activities if paid, on average, 30 hours per week or more.
  • Is earning income through supported employment or work crew/enclave if paid, on average, 30 hours per week or more.

Do NOT check this for a person who:

  • On average, is paid for fewer than 30 hours per week. Instead, check “4: Working part-time (paid work averaging fewer than 30 hours per week).”
  • Attends a facility-based pre-vocational program (e.g., sheltered workshop), but is not participating in paid work for 30 hours per week or more.

4: Working part-time (Paid work averaging fewer than 30 hours per week)

Check this for a person who:

  • Is earning income for working, on average, fewer than 30 hours per week.
  • Is earning income at facility-based employment, on average, fewer than 30 hours per week. This includes pre-vocational work if paid, on average, fewer than 30 hours per week.
  • Is working facility-based employment and is paid by piece-rate not hourly, on average, is paid fewer than 30 hours per week.
  • Is earning income through supported employment or work crew/enclave paid hours and is paid, on average, fewer than 30 hours per week.

Do NOT check this for a person who:

  • Is not working for pay.
  • On average, is paid for 30 or more hours per week of work. Instead, check “3: Working full time (Paid work averaged 30 or more hours per week).”

Note: In sheltered workshops, wages are often paid by piece-rate rather than hourly. The screener only needs to determine if the time involved working for pay is fewer than 30 hours per week. This is most common. Typical full-time program attendance is 30 hours per week; not all hours are typically paid, so paid hours are usually fewer than 30 hours per week.

B. If Employed, Where
Skip this section if in Section A, “1: Retired” or “2: Not Working” was selected.

Check all that apply, as some individuals work in more than one type of employment location.

1:  Paid work where the environment and the work tasks are designed for people with disabilities (e.g., sheltered workshop)

  • This item includes paid work in a sheltered workshop, also known as a community rehabilitation program (CRP), work center, or facility-based employment. These entities are distinguishable from mainstream employers by the fact that the primary mission of the corporation/entity is to provide services to individuals with disabilities and they typically employ a large number of individuals with disabilities in one or more departments or divisions. These entities are typically licensed to pay sub-minimum wages to a group of workers with disabilities. Most provide other rehabilitation and long-term support services besides employment, including day services, therapies, and transportation.

2: Paid work in other group situation for people with disabilities (e.g., work crew/enclave)

  • Work crews and enclaves are group employment arrangements where two or more individuals with disabilities work in a team to perform work that is typically sub-contract work in a community setting. The employer of record is typically the support provider agency (e.g., sheltered workshop/community rehabilitation facility/work center). Because people with disabilities are grouped together, this is considered segregated employment, not community-integrated employment, even if the work crew or enclave does its work in a community setting.

3: Paid work outside the home (situations other than those described in B1 and B2)

  • This is work an individual does that is not done in a sheltered workshop or in the individual’s home, and which is not done as part of participation in a work crew or enclave. In other words, a paid job in the community is any work done for pay that does not fall into one of the other three categories. This includes supported employment, as well as working independently.

4: Paid work at home

  • This is work an individual does in their place of residence, or in an office/work area attached to, or on the grounds of, their place of residence.

C. Need for Assistance to Work
This item is optional for people age 65 or older or under age 18.

This item is mandatory for people aged 18-64, even if the person is not currently working.

Choose one option that best describes the individual’s current or anticipated need.

  • 0: Independent (with assistive devices if uses them)
  • 1: Needs help weekly or less (e.g., if a problem arises)
  • 2: Needs help every day but does not need the continuous presence of another person
  • 3: Needs the continuous presence of another person
  • 4: Not applicable (please explain)

Predicting the need for assistance to work for those not currently working
If the person is not currently working, the screener will need to estimate the level of help the person would likely need to work. This is can be deduced from the person’s overall functioning and abilities. The screener should consider other information such as the frequency of help needed at home, cognition for daily decision-making, IADLs, ADLs and other physical activities, behavioral supports, and skilled nursing needs. The presence of a particular type of disability or health disorder (e.g., cognitive disability, seizures) or guardianship does not automatically mean an individual will need the continuous presence of another person in order to work.

To decide which of the answer choices best represents the level of help needed to work, the screener should follow these steps:

  • If the person worked before and their work abilities are unchanged, indicate the level of job help needed in the past.
  • Deduce from the level of supports indicated elsewhere in the LTCFS:
    • Cognition for daily decision-making
    • Communication impairments
    • Behavioral interventions
    • Assistance with ADLs and IADLs
    • Health care tasks (blood sugar checks, catheters, repositioning, etc.).
  • Consider other factors not captured elsewhere on the LTCFS that create the need for employment supports. Examples include learning disorders, mental health or behavioral challenges, language barrier, or the need for job training or supervision not related to long-term care needs.

4:    Not applicable

  • Should only be selected if the person is severely ill or in a semi-comatose state. Severe disabilities themselves do not render a person unable to work. For a person with marked cognitive and/or physical disabilities, the screener should consider whether selection of 1, 2, or 3 is the most accurate choice.
  • Should not be selected simply because the person is not interested in seeking employment. Even if the person is not expected to seek employment in the near future, the screener should estimate the level of assistance that would be needed if the person did begin work.
  • Explain in the Notes section why it is unreasonable to consider employment for this working-age person, even with continuous assistance from another person.

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6.5 Educational Information

Participating in an educational program is defined as currently and actively enrolled in some type of class and the person needs help from another person, above and beyond reasonable accommodations.

This includes, but is not limited to, degree programs such as high school, technical schools, and colleges.

This does NOT include extracurricular or enrichment programs.

This does NOT include transportation, assistive devices and technologies, service animals, alternative format materials such as Braille, limited-English proficiency interpretation, and simple reasonable adaptation such as taking one class at a time, course load reduction, priority seating, or help with registration.

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6.6 Guardianship

Included in this section of the LTCFS are two questions that require a response of either YES or NO.

Question 1. Does this individual have a guardianship? Yes or No
Select “Yes” when a person has been found incompetent and has a court-appointed guardian of person, estate, or both. If “Yes” is selected, question 2 must be answered.

Question 2. Is the guardianship due to an intellectual disability? Yes or No
Identify whether the guardian was appointed due to an intellectual disability. If a diagnosis is coded as A1-A10 on the Diagnoses Table, select “Yes.” If no diagnosis is coded as A1-A10, select “No.”

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6.7 Diagnoses with Onset Before Age 22

If a diagnosis is coded as A1-A10, select “Yes” if the onset of the condition that caused the diagnosis was prior to age 22.

If a diagnosis is coded as A1-A10, select “No” if the onset of the condition that caused the diagnosis occurred at age 22 or older.

This question does not pertain to all other diagnoses (i.e., not A1-A10).

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6.8 Expected Duration of Diagnosis and Social Security Disability Determination

Included in this section of the LTCFS are three questions that require a response of either YES or NO.

Question 1. Are the needs that are caused by the individual’s primary and secondary diagnosis(es) expected to last more than 90 days? Most short-term injuries (e.g., from bone fracture) and a related need for assistance from another person would not be expected to continue beyond 90 days.

Question 2. Are the needs that are caused by the individual’s primary and secondary diagnosis(es) expected to last more than 12 months OR does the individual have a terminal illness? For purposes of the LTCFS, a terminal illness is defined as a condition where death is expected within one year.

Question 3. Does the individual have a disability determination from the Disability Determination Bureau or the Social Security Administration? In addition to YES or NO, PENDING may be selected as a response to this question. If a person has a presumptive or final disability determination, the screener should select YES in response to this question. PENDING is the correct response when a final decision has not been made about the level of disability for a person who has applied to the Social Security Administration (SSA) for disability-related benefits.

While a young person is transitioned from a Children’s Long-Term Support Waiver program to a publicly funded long-term care program for adults, a screener should select YES in response to Question 3. A child’s disability determination from SSA is valid until he or she reaches 22 years of age. When a young adult who has been participating in the Children’s Long-Term Support Waiver program reaches the age of 18, he or she often transitions to a long-term care program that serves adults. Although a rare occurrence, it is possible that a child with a children’s disability determination from SSA may not meet adult disability determination criteria. A child may first apply for an adult disability determination with SSA when he or she reaches 18 years of age.

In order to participate in a publicly funded long-term care program in Wisconsin, a person must have an adult disability determination from SSA. Although a lack of disability determination does not affect the person’s level of care determination and functional eligibility, it is required in order to meet the programs’ Medicaid non-financial eligibility requirements.

A person can have a disability determination from SSA and NOT meet the definition for a target group that is eligible for adult long-term care programs.

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Last Revised: January 9, 2017