Wisconsin's Functional Eligibility Screen for Mental Health and AODA Services (MH/AODA FS) has been under development since 2001. The MH/AODA FS is a secure on-line functional needs assessment with programmed logic to determine eligibility for the following programs:
- Community Support Program (CSP) - Wisconsin's CSPs provide community-based interdisciplinary social, psychiatric and employment services to adults with major mental illness.
- Comprehensive Community Services (CCS) - CCS is a new program, currently in development, which will provide integrated mental health and substance abuse services to children and adults. CCS has wider eligibility than CSP, including persons with substance abuse diagnoses only.
- Community Options Program (COP) - The Community Options Program Waiver (COP-W) help people get the long-term support they need to remain in their own homes and communities. Community Options serves people who need long-term support, regardless of age or type of disability, who need the same levels of physical or mental health care as nursing home residents do.
The screen will also automatically refer individuals who have co-morbid substance abuse issues to a level one screen for UPC (uniform placement criteria). This UPC tool provides criteria for completing a referral for a complete AODA assessment at an appropriate level of AODA rehabilitation and/or treatment level of care. The MH/AODA FS will also refer individuals with physical health problems and related ADL (activities of daily living) deficits to a long term care functional screen to determine eligibility for funding through a home and community- based waiver.
The MH/AODA FS determines eligibility for mental health/AODA programs for persons age 18 and over. It can be completed for youth age 16 and over to allow for advanced planning. The MH/AODA FS includes the following:
- Community Living Skills: Vocational, benefits/resource management, safety, social, financial, home management, transportation, basic nutrition, general health maintenance, managing symptoms, grooming, and medication management
- Crises and Symptoms: Hospitalizations, ER visits, crises interventions, emergency detentions, physical aggression, suicide attempts, involvement with corrections system
- Risk Factors: Self-injurious behaviors, history of trauma or abuse, housing instability
- Alcohol or other drug problems and treatment
- Psychiatric diagnoses
- Other diagnoses
The MH/AODA FS is an eligibility screen. It is not a complete assessment. The content of the MH/AODA FS was determined by several factors. First of all, it needs to include all of the following eligibility criteria:
- The 1996 Wisconsin Blue Ribbon Commission's (BRC) descriptions of target groups BRC-1 and BRC-2 (either directly or by "translation" from adjectival language to more objective functional items);
- In 1999, DHS 75 administrative rules for AODA rehabilitation and treatment level of services were promulgated. This rule mandates the use of either the Wisconsin UPC or ASAS at the point of referral to an AODA level of service and through out the treatment continuum in including ongoing treatment planning, change of level of care and discharge.
- Admission criteria from the current Wisconsin CSP rule (DHS 63) (either directly or by "translation" from adjectival language to more objective functional items); and
- Eligibility criteria from the new statute establishing CCS (either directly or by "translation" from adjectival language to more objective functional items).
Second, the MH/AODA FS is needed to gather information on the needs of people with mental illness. One major barrier to improving mental health services and systems is the lack of information on the populations served and their social, psychiatric, and healthcare needs. A good deal of the information gathered in the functional screen is intended to address gaps in services and to relate individuals' needs to expenditure data, to allow for systems redesign and new payment methods in the future. MH/AODA FS data will be analyzed to see which factors affect service utilization costs to assist with rate setting in a future managed care system.
Third, functional screens can help with quality improvement efforts on several levels.
- MH/AODA FS data will show differences across counties in populations served or in services provided. For instance, a county can learn that it has far higher rates of emergency detentions or rep payeeship than other counties serving people with apparently similar needs.
- MH/AODA FS information can be tracked over time, for each individual and in aggregate, to see improvements on, for instance, reduced symptoms and increased independence and employment over time.
- Some items on the functional screen are there purely for advocacy reasons, i.e., to gather data to promote more help for primary caregivers, people with post-trauma effects, and people with a mix of physical disabilities and mental illness and substance abuse.
The following "screen development criteria" were used to guide screen development:
- Clarity: Definitions and answer choices must be clear to screeners, the majority of whom are expected to be mental health/AODA case managers.
- Objectivity and Reliability: The screen must be as objective as possible to attain highest possible "inter-rater reliability" (the likelihood that two screeners would answer the same way for a given consumer). Subjectivity must be minimized to ensure fair and proper eligibility determinations. This is particularly challenging in mental health and substance abuse (as opposed to physical disabilities), and will be a primary focus of quality improvement on this initial screen based on screeners' and consumers' feedback and screen testing.
- Brevity: The functional screen is only an eligibility screen, not a complete assessment; for efficiency it should be as brief as possible.
- Inclusiveness: Every individual can be accurately screened with given choices for each question - regardless of adult age, diagnoses, idiosyncrasies, and co-occurring disorders or other life conditions.
- Neutrality: The functional screen should work well regardless of where the person is living (in a facility, in substitute care, transitional housing, or at home).
- Service Neutrality: The functional screen should work well regardless of whether the person is currently receiving any mental health services or is waiting for needed services.
- Cycle Neutrality: The functional screen should incorporate the often cyclical nature of mental illness, and not make people ineligible if they are currently doing well with supports.
The functional screen is "cycle neutral" in the following ways:
- It is not merely a "snapshot" of the present moment, but an averaging over longer periods, usually several months. (See section "2.18 Ranking Fluctuating Needs.")
- "Help" includes "support" - supervision, monitoring, reminding, talking with.
- "Help" includes support and assistance provided by family and friends as well as paid staff.
- The frequency that help is needed has only minor effects on eligibility determination.
The functional screen evolved out of Wisconsin's outstanding success with its long-term care functional screen for frail elders and adults with physical or cognitive disabilities and a children's functional screen. Functional eligibility screens have been essential to improving Wisconsin human service systems. Functional eligibility screens provide all the following:
- Instantaneous (if done on a laptop), accurate, objective eligibility determinations.
- Consistent across all counties, agencies, and individuals determining eligibility.
- Eligibilities for multiple programs done all at once rather than in separate applications.
- Processes for local and state quality oversight and improvement of eligibility processes and decisions for every applicant.
- Understanding people's needs across systems (physical disabilities, mental health, substance use, infirmities of aging, developmental disabilities, health care, social services, residential, transportation, employment needs).
- Confidential data that can be used for:
- Relating costs to screen information function, including hospitalizations, to develop a managed-care rate-setting methodology based on functional screen data.
- Quality improvement of some outcomes over time, for local and statewide improvement (e.g., people are living where they want to).
- County and agency-level analyses of population served (or on wait lists)
- Prioritizing wait lists.
- Recognizing the extent of unpaid supports.
- Quality improvement across counties.
- Identifying gaps between needs and services.
- Advocacy for better funding and systems improvements.
Mental health status is very different from physical disabilities, infirmities of aging, or developmental disabilities. Mental health factors are far more difficult to measure "objectively." Mental health status varies much more over weeks, days, even hours. Most mental health service needs (thus costs) may relate to intangible factors such as stress, mood, relationships, specific events, more than to "objective" factors like demographics, diagnoses, and current functional status. Most importantly, the functional screen focuses on needs, i.e., deficits, which seems to violate the principles of strengths-based, consumer-focused, recovery-oriented models. For all these reasons, the functional screen has met with less enthusiasm than previous screens. So why a MH/AODA FS? For these reasons:
- Wisconsin's Long-Term Care Functional Screen (LTC FS) has succeeded despite initial doubts and cynicism. National experts told us it was impossible to correlate program costs with functional status; others have tried and failed for decades. Stakeholders (counties, advocates, consumers and families) were skeptical. Through a participatory process of developing and refining the screen over time, stakeholders came to embrace the LTC FS, which now has had success unprecedented in the U.S. 80 percent of rates for the Family Care program are based on functional screen information. Counties and agencies are voluntarily using the LTC FS to decide rates for services such as residential settings and day treatment. The LTC FS can assign specific levels of care and eligibilities more consistently and accurately than individual experts.
- Mental health system redesign, for which thousands of Wisconsin stakeholders have worked for years, cannot move forward without more information on who's being served and what their needs are.
- Many mental health consumers and their families have reported to the Department that eligibility decisions can vary across counties, agencies, and individuals. This is a serious problem that must be corrected, as it is fundamentally unfair to consumers and families. The MH/AODA FS provides a structured way to look at information to reduce, as much as possible, variation among screeners. The programmed eligibility logic represents experts' thinking and yields consistent results.
- Most mental health consumers who participated in initial testing of the MH/AODA FS are positive about it, despite the fact that it is "deficit-based." (One is eligible for services only if one has a need for those services; hence, functional eligibility screens are needs-based.)
For these reasons, development of the MH/AODA FS is continuing. Only time, and everyone's participation, will prove success. The MH/AODA FS remains a work in progress and users' participation as co-developers is absolutely critical to that progress.
The MH/AODA FS has been developed by several workgroups since 2001.
- Winter 2001/02 - A small group of DHS staff (social workers and nurses) developed a preliminary draft screen and eligibility logic based on BRC criteria.
- Spring '02 - MH Redesign Stakeholders' Screen Workgroup revised initial draft.
- Summer '02 - Initial screener trainings were done and the screen was released for the first phase of testing in the four demonstration counties.
- Summer '03 - Inter-rater reliability tests were done.
- Winter '03 - Screen and logics were revised based on above testing and programmed into an on-line application with entry-level edits and "instant" eligibility determinations.
- Spring '04 - New screen release, screener trainings, and second phase of testing.
NOTE: The MH/AODA FS is still being developed! Screen implementation is an iterative process in which the screen and instructions are improved over time based on feedback from screeners, consumers, and other interested parties. On-going quality assurance and quality improvement processes will need to be established so that the MH/AODA FS works well for every individual needing services.