- 8.1 Identifying Primary and Secondary Diagnoses
- 8.2 Communication
- 8.3 Memory Loss
- 8.4 Cognition for Daily Decision Making
- 8.5 Physically Resistive to Care
By the end of this module the screener should be able to:
- Accurately complete the Communication, Memory, Cognition for Daily Decision Making, and Physically Resistive to Care sections of the LTCFS.
- Describe how Memory Loss in this module is addressed differently from other areas of the LTCFS that collect cognition information.
- Distinguish between a competent person refusing help and a person being "physically resistive to care."
- Identify and correctly enter primary and secondary diagnoses that cause any need identified in this module.
Cognitive Impairment: A cognitive impairment in the Adult LTCFS is defined as a permanent impairment of thought due to a severe and persistent mental illness, dementia, brain injury, intellectual/developmental disability, or other organic brain disorder.
- A cognitive impairment does not include temporary impairment due to medications and/or substance use intoxication.
- A cognitive impairment does not include temporary impairment due to a temporary medical condition such as infection, electrolyte imbalance, or dehydration.
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 who 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.
Communication includes the ability to express oneself in one's own language, including non-English languages, American Sign Language (ASL), or other generally recognized non-verbal communication. For the purposes of the LTCFS, a person’s ability to communicate should be assessed in the context of their residence and not in regard with their ability to communicate with people in society at large.
REMINDER: A person with a diagnosis of deafness has hearing loss that cannot be overcome with the use of hearing aids. A person with deafness may be able to fully communicate with others by reading lips, speaking, using written language, or by using sign language. For this person, the selection of 0: (Can fully communicate with no impairment or only minor impairment) is correct.
- 0: Can fully communicate with no impairment or only minor impairment (e.g., slow speech)
- 1: Can fully communicate with the use of an assistive device
- 2: Can communicate ONLY BASIC needs to others
- 3: No effective communication
0: (Can fully communicate with no impairment or only minor impairment [e.g., slow speech])
Check this for a person who communicates fully (feelings, thoughts, complex or abstract ideas beyond basic needs):
- With a speech impediment (stutters, slurred speech, etc.) but is able to be understood by others.
- With a delayed response.
- In a non-English language.
- In American Sign Language or signed English.
- In writing (including cell phone texting), but is able to fully communicate verbally.
1: (Can fully communicate with the use of an assistive device) includes communicating through an adaptive device designed to help aid a person when expressing themselves.
Check this for a person who:
- Uses a computer, cell phone, or other communication device as their only means of communicating their feelings and ideas in detail, because they are unable to fully communicate verbally.
- Uses a voice amplification device or battery-powered artificial larynx.
2: (Can communicate only basic needs to others) includes, but is not limited to, the person’s ability to tell their immediate family, friends, or caregivers they are hungry, thirsty, in pain or discomfort, or need to use the bathroom. Such a person may have receptive language, but is unable to participate fully in a two-way exchange of information involving abstract ideas, concepts, or feelings due to limited expressive language.
Check this for a person who:
- Uses a picture or word board and is unable to communicate more than their basic needs.
- Can be understood by their ongoing caregiver, parent, etc., and not a new person meeting them for the first time (e.g., new caregiver, 911 operator, etc.).
- Is nonverbal, but communicates by body language, answering yes/no questions by blinking their eyes, raising a hand, or leading a person to what they want or need.
- Has rambling or incoherent speech, but is still able to communicate their basic needs.
- Speaks in short phrases or with few words, but fully understands verbal communication and is able to communicate their basic needs or preferences.
- Has aphasia and only speaks one or a few set words, but fully understands verbal communication.
3: (No effective communication) is evident when a person with a health condition, that physically or cognitively limits their ability to communicate, is unable to express their basic needs or preferences. This includes, but is not limited to, a person physically or cognitively unable to tell someone they are hungry, thirsty, in pain or discomfort, or need to use the bathroom (e.g., a person with late stage dementia, a neurodegenerative disease, profound intellectual disability, etc.).
REMINDER: On the LTCFS, the term “assistive device” does not include hearing aids.
REMINDER: The Communication item is not meant to capture all nuances of communication. As a general rule, if a person can’t fully or consistently meet a higher functioning level with communication that is efficient and accurate, select the lower functioning level that most closely approximates their ability.
A person’s memory loss should be reviewed in the context of their health, safety, or risk during a typical day. At issue is the severity of the person’s memory loss.
Good interviewing skills will allow the screener to gather information about the person’s true memory capacity. Here, the screener is not required to obtain verification from a health care provider to support what is selected. A screener should observe and collect significant evidence to support their selection. To help evaluate a person’s memory, the screener may want the person to complete a short memory test (e.g., animal fluency test, mini mental status exam). The level of memory loss indicated here should correlate with the person’s need for assistance with ADL and IADL tasks.
REMINDER: Claims of memory loss made by the person being screened or opinions voiced by family members should not simply be accepted as fact when what is reported is inconsistent with what the screener observes. Such opinions should be supported by the screener’s observations, collateral information, or other evidence, such as medical records.
Memory Options (at least one must be checked):
- 0: No memory impairments evident during screening process
- 1: Short-Term Memory Loss (seems unable to recall things a few minutes up to 24 hours later)
- 2: Unable to remember things over several days or weeks
- 3: Long-Term Memory Loss (seems unable to recall distant past)
- 4: Memory impairments are unknown or unable to determine. Explain why.
If 0: (No memory impairments evident during screening process) is selected, that is the screener’s only selection and no other box should be checked.
We all forget things from time to time and some forgetfulness is normal. Everyday forgetfulness that does not interrupt the person’s daily life or activities is not memory loss.
Memory loss is not:
- Occasionally forgetting where you parked your car or left your keys.
- Being unable to recall the specific calendar date or someone else’s telephone number or address.
- Occasionally forgetting appointments.
- Occasionally forgetting to take prescribed medication.
- When a person with a low IQ has difficulty remembering due to their cognitive impairment that limits their ability to retain information and reason.
1: (Short-Term Memory Loss) is defined as the inability to recall recent events or new information, a few minutes up to 24 hours later. Memory loss occurs when new events or information are not transferred to the person’s memory once their attention has shifted and they are then unable to recall what just transpired.
A person can have poor short-term memory, but have good long-term memory (e.g., a person in an early stage of dementia). Indicators of short-term memory loss can include, but are not limited to, when a person is unable to recall:
- When or what they last ate.
- The name of person they met moments ago.
- A conversation earlier in the day.
- They repeatedly ask the same questions.
- They have left water boiling on the stove or food cooking on the stove or in the oven, etc.
- Where an item was placed and they cannot re-trace their steps to find the “lost” item.
- Where an item was placed and a “lost” item is found in inappropriate place (e.g., house keys in the freezer).
2: (Unable to remember things over several days or weeks) is a level of memory loss evident when a person does not remember recent or special events from the last few days or weeks (e.g., a birthday gathering, a recent holiday, seeing a movie at a theatre, dining out for a fish fry, etc.).
3: (Long-Term Memory Loss) is defined as the inability to recall memories that were stored years ago. Long-term memory loss occurs because of a neurodegenerative process or trauma.
Indicators of long-term memory loss can include, but are not limited to, when a person is unable to:
- Recognize family members.
- Recall their date of birth.
- Recall memories of childhood or special events.
4: (Unable to determine. Explain why) is the correct selection for a person with cognitive or other deficits when the screener is unable to determine whether the person being screened has any memory loss.
The sections of Memory Loss and Cognition for Daily Decision Making do overlap, but the distinction helps clarify the person’s specific need for assistance. Follow the definitions closely.
This section is meant to capture the person’s ability to make daily decisions beyond those that involve managing their medications and finances. These two cognition-related tasks are captured in the IADL section of Module 4.
Cognition for Daily Decision Making Options:
- 0: Person makes decisions consistent with their own lifestyle, values, and goals
- 1: Person makes safe, familiar/routine decisions, but cannot do so in new situations
- 2: Person needs help with reminding, planning, or adjusting routine, even with familiar routine
- 3: Person needs help from another person most or all of the time
Options 1, 2, and 3 include the ability to make routine decisions and exclude the ability to make non-routine decisions. Some examples of routine, daily decisions a person typically makes independently can include, but are not limited to:
- What time to get up or go to bed.
- What to do with their free time (e.g., whether to watch TV, work on a puzzle).
- Whether to go visit friends, attend activities, shop, etc.
- Using scheduling cues such as clocks, calendars, or reminder notes.
The inability to make such routine daily decisions without help may indicate a cognitive deficit.
It is normal for adults to seek advice from others when making some decisions. Seeking input from others does not automatically indicate a lack of cognitive function. Some examples of non-routine decisions a person typically does not make independently, but makes with input from others can include, but are not limited to:
- Household or vehicle repairs.
- Larger purchases (e.g., new vehicle, appliances, furniture).
- Purchase of insurance (e.g., health, homeowner, or vehicle).
- Applying for assistance (e.g., Medicaid, food stamps, Homestead Credit).
- Surgery or medical treatment.
- Change of residence.
- Sale of their house.
- Financial investments.
- Enrolling in a LTC program.
The inability to make such non-routine decisions may not indicate a cognitive deficit.
0: (Independent—Person makes decisions consistent with their own lifestyle, values, and goals)
Check this for a person who:
- Can safely get through a day without needing a cue or reminder.
- Only needs assistance making non-routine decisions.
- Understands when and how to call for help if a problem or emergency arises.
- Can be left alone for short or long periods of time.
1: (Person makes safe, familiar/routine decisions, but cannot do so in new situations)
Check this for a person with a cognitive impairment who:
- Can safely get through a day without needing a cue or reminder, but is unable to problem solve a new event or situation that is typically a routine daily decision for others.
- Can safely get through a day without needing a cue or reminder, but is unable to respond appropriately to unexpected events, emergencies, or problems typically a routine daily decision for others (e.g., when the person is locked out of their apartment and doesn’t know what to do).
- Can safely get through a day without needing a cue or reminder and is able to be left alone for up to an hour, but not longer.
- Can safely get through a day without needing a cue or reminder, but does not have the capacity to know when to call for help (e.g., person wouldn’t call 911 when appropriate to do so).
- Can safely get through a day without needing a cue or reminder, but does not have the capacity to know who to call for help (e.g. person wouldn’t know who to call when their toilet stops working).
2: (Person needs help with reminding, planning or adjusting routine, even in familiar routine)
Check this for a person with a cognitive impairment who:
- Cannot safely get through a day without needing cues, reminders, or guidance to initiate, plan, or complete routine everyday activities, but can be left alone for up to an hour. For example, without assistance, the person would spend their day in bed or on the couch, watching television and sleeping; although they do not require line-of-sight supervision, they do require help during some periods of the day.
- Needs cues or reminders to eat, bathe, dress, or brush their teeth, but can be alone for up to an hour.
3: (Person needs help from another person most or all of the time)
Check this for a person with a cognitive impairment who:
- Cannot be left alone for any length of time.
- Needs line-of-sight supervision.
- Needs one-to-one assistance due to a cognitive impairment.
This section addresses those persons who have a cognitive impairment and who are physically resistive to their care(s). A person is physically resistive when they become combative; they kick, bite, punch, or pinch another person during a care task; and in doing so, injury is possible and care is impeded.
A person is not considered physically resistive to their care when they avoid a task, ignore a prompt or cue to complete a task, or refuse to complete a task. Examples of behaviors that are not considered physically resistive include, but are not limited to: a person walking away from another person prompting them to complete a task, or when a person turns their head away from another person assisting them with oral hygiene.
When determining if a person is physically resistive to care, the types of care considered are only those listed on the LTCFS as an Activity of Daily Living (ADL) or an Instrumental Activity of Daily Living (IADL) care task.
Excluded in the module are those cares NOT listed on the LTCFS as an ADL or IADL care task. For example, a person being physically resistive to assistance in the completion of hygiene or grooming tasks is not recorded on the LTCFS.
In this section, while a person must have a cognitive impairment in order to indicate they are physically resistive to care, it is not necessary that they have a guardian or other authorized representative appointed or activated (e.g., activated power of attorney for health care, durable power of attorney). However, there should be a medical diagnosis with collaborating evidence in other parts of the screen, indicating that a significant cognitive impairment is present. Included in this section is a person physically resistive to their care(s) due to the cognitive impairment associated with their severe and persistent mental illness.
Physically Resistive to Care Options:
- 0: No
- 1: Yes, person is physically resistive to cares due to a cognitive impairment
0: (No) includes, but is not limited to, a person who:
- Is resistive to care(s), but does not have a cognitive impairment.
- Is uncooperative during the provision of their care(s), but is not physically resistive to their care(s).
- Is competent and refuses care(s).
- Reacts verbally by complaining, crying, or repeatedly says “No” when care is suggested or during the provision of their care(s).
1: (Yes, person is physically resistive to cares due to a cognitive impairment) includes, but is not limited to, a person who:
- Strikes out or throws objects at a caregiver when care is provided.
- Kicks, punches, or pinches another person when care is provided.
REMINDER: This section addresses physical combativeness during the provision of ADLs and IADLs captured on the LTCFS (e.g., bathing, toileting). It does not address ongoing behavior patterns that involve violent or offensive acts. Such behaviors requiring interventions are captured in Module 7, Health-Related Services Table and Module 9, Behaviors/Mental Health.
REMINDER: A screener would NOT select "Yes" for a competent adult who refuses care. All competent adults have the right to refuse any services. For each ADL and IADL task, the screener is to indicate the help the person needs, whether or not they are receiving the help now and whether or not they accept the assistance. If the person's refusal to accept assistance puts them at risk, the screener indicates that in the Risk Module.
REMINDER: Although a person’s behavior of being physically resistive to care may be part of a larger pattern of offensive or violent behavior, the two do not always occur together. For example, an otherwise docile and cooperative person may resist the intrusive nature of help provided with their bath.