Module 1: Overview

1.1 Introduction and history

Wisconsin’s Mental Health and Substance Use Disorder Functional Eligibility Screen (hereafter “the screen”) was developed in 2001. It is a secure online screen with programmed logic to determine eligibility for mental health and substance use disorder programs for adults (18 and over). It can be completed for youth (16 and over) to allow for advanced planning.

Note: This screen is meant only for adults with mental health and/or a substance use disorders. This screen determines eligibility for community-based, psychosocial rehabilitation programs. If you are looking for services for children, please see the Children’s Long-Term Support Functional Screen. If you are looking for services for adults needing long-term care options, please see the Adults Long Term Care Functional Screen.

The screen determines eligibility for the following community-based psychosocial rehabilitation programs:

Community Support Programs (CSP) – CSP provides interdisciplinary social, psychiatric, and employment services to adults with serious mental illness.
Comprehensive Community Services (CCS) – CCS provides integrated mental health and substance use services to children and adults. CCS also serves people with only a mental health or substance use disorder diagnosis.
Community Recovery Services (CRS) – CRS assists adults living with a serious mental illness reach their full potential. Participants receive community living supportive services, peer support services, and supported employment services.

The screen includes the following categories:

Basic information: Name of the applicant (the person you are screening to establish medical necessity of services.), date of birth, screen type, etc.
Referral source: Source of referral, primary source of screen information, and where screen was conducted.
Demographics: Insurance, ethnicity, race, interpreter, and court order information.
Contact information: Legal guardian/person responsible for making decisions about medical care, activated power of attorney for health care, and/or other relevant contact information for people such as adult children , spouse, etc.
Living situation: Current residence and where the individual would prefer to live.
Vocational information: Current work status, interest in a job, needing assistance to find/apply for work, needing assistance to work, and needing assistance with schooling.
Community living skills inventory: Benefits/resource management, basic safety, social/interpersonal skills, home hazard identification, money management, basic nutrition, general health maintenance, managing psychiatric symptoms, hygiene/grooming, taking medications, monitoring medication side effects, transportation, and physical assistance.
Crises and situational factors: Use of emergency rooms, crisis intervention, and/or detox units; psychiatric inpatient stays; Wis. Stat. ch. 51 emergency detentions; physical aggression; involvement with the corrections system; and suicide attempts.
Risk factors: Self-injurious behaviors, substance use and the outcomes of substance use, history of trauma or abuse, housing instability, and intensity of treatment/functional severity.
Mental health and substance use disorder diagnoses: Applicable diagnoses per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
Other diagnoses: Diagnoses related to brain/central nervous system, developmental disability, endocrine/metabolic system, heart/circulatory system, musculoskeletal/neuromuscular system, respiratory system, reproductive system, sensory system, and immune system.

1.2 Purpose

The screen gathers information on physical disabilities, mental health/substance use, infirmities of aging, developmental disabilities, health care, social services, housing, transportation, and employment needs to inform clinical staff of an applicant’s individualized needs.

The screen provides a structured mechanism to reduce, as much as possible, variation among screening results. The programmed eligibility logic represents the thinking of experts and yields consistent and accurate results.

The screen is required for adult admissions to CCS and CRS.

The screen is voluntary for admissions to CSP. It is best practice for the screen to be used.

If the screen indicates that the applicant has physical health problems and related activities of daily living deficits, a long-term care functional screen is recommended. The long-term care functional screen determines eligibility for funding through home and community-based services waiver program(s) such as Family Care, Include Respect I Self-Direct (IRIS), Family Care Partnership, and the Program of All-Inclusive Care for the Elderly (PACE).

If an applicant has substance use issues or a diagnosis of substance use disorder, an additional substance use disorder screen is recommended.

1.3 Guiding principles

The following principles guided the development of the screen.

Clarity: Definitions of terms and answer choices on the screen must be clear to every screener.
Objectivity and reliability: Subjectivity of the screen must be minimized to ensure fair and proper eligibility determinations.
Brevity: For efficiency purposes, the screen must be as brief as possible.
Inclusivity: Regardless of age, race, diagnoses, idiosyncrasies, co-occurring disorders, and other life conditions, every individual can be accurately screened with given choices for each question on the screen.
Neutrality: The screen should yield accurate results regardless of circumstances surrounding an applicant’s experiences such as:
- Where the applicant is living (in a facility, in substitute care, transitional housing, or at home).
- Whether the applicant is currently receiving any mental health or substance use services or is waiting for needed services.
- The cyclical nature of mental illness and substance use disorders (people being found ineligible if they are currently doing well with supports).

1.4 Eligibility criteria

Screen eligibility is based on:

Individuals identified as having a serious mental illness or substance use disorder.
Criteria from Wis. Admin. Code ch. DHS 36.
Criteria from Wis. Admin. Code ch. DHS 63.

1.5 Other functional screens

Children’s Long-Term Support Functional Screen

The Children’s Long-Term Support (CLTS) Functional Screen captures the needs of a child in a variety of developmental, behavioral, health, and daily living activities. It provides functional eligibility determinations for several programs, four functional levels of care, and three target group designations for children from birth through age 21.

Adult Long Term Care Functional Screen

The Adult Long Term Care (ALTS) Functional Screen is for long-term care programs for people who are frail elders and people who have physical disabilities, dementia, a terminal illness, or intellectual/developmental disabilities. A person must be 18 to participate in a publicly funded long-term care program for which the ALTS Screen determines eligibility. These programs are Family Care, Family Care Partnership, PACE, and IRIS. Early screening is available for people at 17.5 years old to assist planning for transition to the adult long-term care system.

Personal Cares Screening Tool

The Personal Cares Screening Tool (PCST) collects information on an individual’s ability to accomplish activities of daily living, instrumental activities of daily living, and medically oriented tasks that are delegated by a registered nurse. Activities of daily living include bathing, dressing, grooming, applying prosthetics/braces/anti-embolism hose, eating, mobility, toileting, and transferring. Medically oriented tasks include tasks such as assisting with getting medication from hand to mouth, glucometer readings, urinary catheter site care, administering a suppository, or administering a tube feeding.

1.6 Screener role and qualifications

The screen is completed by a mental health and/or substance use disorder practitioner with input from applicants and supports. All people administering the screen must meet the following conditions.

Employment status

Screeners must be direct or contracted employees of Tribal nation or county agencies designated by DHS as screening agencies.

Education and experience

The screener must meet at least one of the following conditions:

The screener has at least an associate degree (preferably in a health and human services-related field) and at least one year of experience working with at least one of the screen’s target populations.
The screener’s combination of post-secondary education and experience is approved by DHS.
The screener has a written plan for formal and on-the-job training to develop the required expertise that is approved by DHS.

Training requirements

DHS requires all new screeners to read this manual and complete the online course on the screen.

1.7 Screen lead role and qualifications

Each Tribal nation or county must assign a screen lead. The screen lead’s responsibilities include:

Facilitating the agency’s work regarding the screen, which includes training and mentoring new screeners.
Ensuring all screeners understand how to complete the screen in a manner that upholds the integrity of the tool.
Pulling a random sample of screens completed by the agency and reviewing them to ensure they meet quality control standards.
Serving as the first point of contact when screeners are unsure about how to complete a question or address a unique situation.

DHS maintains a database of screen lead names and contact information. Each Tribal nation or county is responsible for providing updates to DHS regarding the name and contact information of their screen lead to ensure the state database containing this information is accurate and complete.

If your Tribal nation or county has assigned a new screen lead, contact dhsdctsfs@dhs.wisconsin.gov.

1.8 Quality assurance guidelines

Screeners should use their professional interview skills to gather information in a way that is appropriate for a given applicant. The screener will need to ask questions in a variety of ways, use communication strategies that best meet the needs of the applicant 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 applicant. A release of information must be signed by the applicant to access collateral information.

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 applicant and their significant others that may indicate undisclosed needs.

Screeners should not interpret questions or make assumptions about how to proceed in situations that are unclear. Instead leave the question(s) that prompted the concern blank and take notes on the situation. Consult the agency screen lead. If guidance is not found in this manual, the agency screen lead will contact DHS. Following this approach ensures interpretations are kept consistent and communicated to all screeners.

The screen forms the basis of a comprehensive assessment by a mental health and substance use disorder provider. To avoid repeating the questions included in the screen during the comprehensive assessment, the provider may ask the applicant to sign a release of information, which allows the screener to electronically authorize the provider to see the applicant’s screen. The provider may do a complete assessment building from the information shown in the screen.

When using translators or interpreters during a screening interview, screeners must ensure interpreters 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 applicant, 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 applicant are not allowed.

Refer instances of alleged Medicaid fraud to the DHS Office of the Inspector General at 877-865-3432.

Consent

The applicant should consent to completion of the screen and its submission to DHS. No screen should be completed without the applicant’s informed consent. The applicant needs to know what’s involved in the screening process and that refusal to participate could affect their eligibility for services. Document the applicant’s (and guardian’s if applicable) consent declaration in the basic information page’s notes section. Screeners should direct questions about informed consent to the agency’s screen lead.

Interview

The screening process requires contact with the applicant being screened. No screen should be completed without a meeting with the applicant, even if they have communication difficulties. An in-person interview is best practice and is encouraged.

The in-person interview can take place in any setting, including the applicant’s residence, a group home, day services center, a hospital, or a restaurant. Applicants may have collateral informants (such as family, significant others, formal or informal caregivers, health care providers, and agencies serving the applicant) present during the screen if they choose to do so. It may take more than one contact with the applicant to complete the screen.

In-person interviews can assist in gathering more information on how the applicant is living in their own home, their hygiene, and other factors that may be harder to note through telehealth. If meeting in-person is not possible, telehealth may be used to complete a screen if the appointment meets ForwardHealth guidelines.

If the screener uses telehealth, then change the location of the screen to other and type telehealth in the notes section. It’s important to reach out to collateral contacts (with permission from the applicant) to get more information on the applicant’s hygiene and living situation if you cannot see it in person.

Screeners should direct questions regarding this guidance to the agency screen lead.

Health and well-being discussion

The screen can be completed in any order. It should be completed as part of a larger recovery-focused conversation about the applicant’s overall health and well-being, not just their needs.

Confidentiality

All professionals involved in the screen have an obligation to protect the confidentiality of the information collected. This includes following the requirements established by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). A release of information must be signed by the applicant, their guardian, or their power of attorney to access the applicant’s medical records, educational records, or other records necessary to complete a screen.

Tell applicants:

"The Mental Health and Substance Use Disorder Functional Screen is completed through a password-protected online system. A completed screen can only be seen by coworkers of the screener who also perform screens for the same agency and designated DHS staff. Information about a completed screen, the date the screen was completed, and the agency that completed the screen can be viewed by all screeners across the state. However, the details of an individual screen can only be seen by the agency that completed the screen and designated DHS staff."

Note-taking

All sections of the screen allow screeners to type detailed information provided by the applicant.

Quality notes:

Assist practitioners in gathering information that may not be collected through the screen.
Track an individual’s progress, or lack thereof, over time.
Provide the status of services an individual is receiving to meet their functional needs.
Make it easier to find potential errors made throughout the screen if the screen returns unexpected results and the screener requests a review from DHS.

Sections outlining the functional needs should include clear justification as to why particular answers were selected.

It is best practice for notes to be dated and initialed by the screener.

It is not appropriate to copy notes from previous screens and change the date on them.

For sections such as basic information, demographics, or living situation, it is appropriate to state that there have been no changes since last screen. However, for sections such as the community living skills inventory, crisis, and risk factors, it is not appropriate to state no difference since last screen.

1.9 Limitations

It is recognized and shown in research that screens like this one are imperfect. According to national studies, limitations of functional screens include:

Health care and institutional providers tend to overrate the applicant’s dependency on others.
Guardians, spouses, and family members often tend to overrate the applicant’s dependency on others.
Applicants may be unable to provide accurate information or may exaggerate or downplay their abilities or their need for assistance.
An applicant’s status and abilities fluctuate, making it difficult to choose the most accurate frequency at which help is needed.
Applicants can provide conflicting information at different times or to different screeners.
Screen answers vary somewhat depending on whether the screener knows the applicant well or not.
Screen answers vary somewhat depending on the profession of the screener.
Some subjectivity remains in some questions, especially in the mental health field.

1.10 Strategies to mitigate limitations

Inter-rater reliability

The goal of the screen is to gather the most accurate possible description of the applicant’s abilities and their needs, which includes ensuring inter-rater reliability. Inter-rater reliability is defined by the American Psychological Association as “the extent to which independent evaluators produce similar ratings in judging the same abilities or characteristics in the same target person or object.”

To ensure inter-rater reliability:

Follow the definitions in this manual. All questions should go to the agency screen lead.
Ask “What objective information do I have? What would a screener from a different gender identity, culture, class, agency, etc., mark based on this information?” Do not mark an answer based on opinions. Consider what is typical for members of the person’s culture. All questions should go to the agency screen lead.
Ask “Does this answer reflect what might be in an initial care plan for this applicant?”
Collect detailed information from multiple sources, including collateral contacts.
Neither the applicant’s opinions nor the screener’s input alone would generate accurate screens. For many items, functional status is ranked by the frequency at which the applicant needs help from other people. If someone is marked as needing help from others, then it is expected that either the applicant is getting the help OR they are suffering negative outcomes or risk thereof from not getting the help. To that end, it is important to gather information from not just the applicant, but from others who know and/or support them such as family members, paid or unpaid caregivers, friends, or other natural or paid supports. Once you have gathered information from the applicant and their supports, then the screen should be completed.
Take cultural differences into account. If you are unclear about an applicant’s cultural differences, work with the agency screen lead to research the culture at hand or to re-assign the screen to an individual familiar with that culture. Screen leads should facilitate regular times for screeners to discuss screen questions, especially concerning cultural competence and inter-rater reliability.

Conflicting information

Sometimes screeners will get different information from different sources. Applicants may function less independently in day care facilities or institutions than they do at home. Staff at these facilities may perceive more dependency than family or peers in the community may perceive for the applicant. Screeners should use their best professional judgment to describe the applicant’s functional abilities as accurately as possible given all the information from multiple sources. If the proper answer is not clear, screeners should discuss the issue with their agency’s screen lead.

Applicant understates or overstates needs

Applicants may understate or overstate their needs. If you suspect the applicant is understating or overstating their needs, ask:

Have they been doing the task adequately without significant hardship?
Does someone help them with the task now?
What have they done (or what would they do) if assistance were not available?
What would the consequence be if assistance were not available?

If no hardship results from a lack of assistance, it suggests that the applicant is in fact able to do the task on their own. Screeners should use their best professional judgment to describe the applicant’s functional abilities as accurately as possible given the information collected. If the proper answer is not clear, screeners should discuss this with the agency’s screen lead.

Needs inventory and practitioner-identified needs

Program eligibilities are based on the need for program services. Thus, the screen is based on an applicant’s diagnoses, symptoms, and need for help from others (functional impairments). Recovery-oriented systems of care reject the professional knows best model and require that the applicant take an active role in their care. However, mental health and substance use disorder practitioners are responsible for recognizing functional impairments or a need for help that the applicant may not recognize.

It is critically important to consider how the individual would be doing if whatever supports for the individual currently in place were taken away. Would they be able to continue doing the task independently? If yes, you can mark independent. If they would struggle or fail to complete the task on their own, select that they need assistance.

Problematic or unhealthy alcohol and/or drug use

Substance use (alcohol and drug use) is a term that includes the full spectrum of unhealthy use. This spectrum can range from risky use to substance use disorder. Risky substance use is the frequency of consumption in amounts that increase the likelihood of significant impairments. Substance use disorder is when an individual not only has significant impairments or distress due to substance use but the impairments/distress occurs repeatedly and leads to negative consequences.

Significant impairments or distress can include failure to meet responsibilities, physical health problems, mental health problems, dangerous behaviors, social issues, and legal problems. If the screener identifies that alcohol or drug use caused significant impairment or interferes with activities of daily living such as preparing food, grooming, work, socializing, and obtaining stabilized housing, the screener likely will indicate a need for further assessment and assistance with task management to encourage autonomy and well-being.

Screeners need to establish an environment that is comfortable, non-confrontational, non-judgmental, and empathetic where individuals feel they can express their thoughts and feelings about substance use without fear of judgment. Anxiety can affect how the screener asks the question and how the applicant responds to the question. Screeners can help applicants by creating the conditions needed for their applicants to feel safe and free from judgment when answering the screening questions.

Be genuine: This helps create a secure, trusting relationship between you and the applicant. This trust contributes to a feeling of safety, which may help the applicant engage in the screening process more comfortably. 
Show unconditional positive regard: The applicant will feel free to express their thoughts and feelings without fear of judgment. 
Apply empathetic understanding: This fosters a positive relationship between the screener and applicant and represents a mirror that reflects the applicant’s thoughts and emotions to help them gain more insight into themselves and their struggles.

Communication strategies and substance use

Always remember to focus on the problem, not the applicant.
Address confidentiality concerns:
- Be honest and let them know who will or will not have access to their screening.
- Individuals who have experienced domestic violence may feel more open knowing that the individual who hurt them will not have access to the information on the screening.
Ask permission: “Would it be alright with you if I asked you some questions about your drinking?”
Ask for facts rather than displaying judgment.
Ask general questions to get the conversation started, then dig deeper and ask for specifics around the type of substance used, frequency, and when they used last.
Use transparency:
- Explain why you are asking—be open about your reasons.
- Explain the need to why you are asking specific questions.
Normalize the problem (if appropriate) and/or the anxiety (“Many people who struggle with substance use have similar struggles”).
Shift the approach or move to the next question when encountering resistance in responding to a question and come back to that question later.
Some individuals may feel ambivalence (or resistance) about participating in the screening on substance use. Ambivalence stems from fear of change or fear of consequences if they answer questions truthfully. Confrontational approaches will only increase applicant resistance and discord in the relationship.

Use the OARS Model. OARS is a skills-based model of interactive techniques adapted from an applicant centered approach using motivational interviewing principles.

The OARS Model includes four basic skills:

Open questions:

“How would you like things to be different?”
“What do you think you will lose if you give up ___?”

Affirmations:

“You are clearly a very resourceful person.”
“You handled yourself really well in that situation.”

Reflective listening without judgement:

“So, you feel…”
“It sounds like you…”
“On the one hand you want… and on the other hand…”

Summarizing:

“Let me see if I understand so far…”
“Here is what I’ve heard. Tell me if I’ve missed anything.”
“What I’m hearing from you is that you don’t like this idea. Is that an accurate interpretation?”

Frequency of need for assistance

The frequency of need for assistance checked on the screen should reflect actual needs as closely as possible. Do not check a frequency based on what the applicant says they need or don’t need. The screener’s opinion should not factor into the decision on what frequency to check. Check the frequency that most screeners would agree should be in the service or treatment plan for the applicant. Check a given frequency that:

Includes support provided through talks, reminders, monitoring, and supervision provided by family, friends, and/or paid staff. Example: If the family provides medication reminders every day, daily assistance is the frequency of help needed from others.
Reflects if the individual verbally denies the need but accepts the help, including visits to monitor, cue, or negotiate.
Reflects if the individual currently refuses any help or discussion of the topic. The screen is intended to indicate what the applicant needs, even if they refuse the help. An individualized service plan is negotiated with the applicant, but the screen looks only for needs.
Reflects the need even if the need exceeds a provider’s capacity to provide help at that frequency. The screen seeks statewide consistency in indicating mental health and substance use service needs. Counties vary in how they distribute these services. Screeners need to think beyond their own agency to ask what screeners in other counties would indicate for an individual’s needs. This manual is intended to help you do that.
Reflects the frequencies of practitioner contacts with the individual ff the applicant is a current consumer of mental health and substance use services. In this way, completing the screen is like developing the applicant’s individualized service plan. If the applicant declines the services, the services should still be marked on the screen.

Remember, the screen looks for help needed from anyone, not just mental health and substance use practitioners.

Ranking fluctuating needs

Mental illnesses and substance use disorders are often cyclical, with varying levels of symptoms and functioning. The screen is not merely a snapshot of the present moment, but an averaging over longer periods, usually from several months up to two years. Every day mental health and substance use disorder practitioners make judgments based on this mix of point in time and historical views to determine the frequency of contacts from the current point in time up to the next few weeks or months. People’s needs will change. Predictions are only approximate. However, these need determinations reflect expert judgment (and sometimes research data) of the frequency of interventions needed to promote recovery and prevent crises.

For some community living skills, screeners are asked to indicate the approximate frequency at which help is needed. The choices include:

Independent: The applicant does not require assistance with tasks. They can complete a task, support themselves emotionally, and monitor symptoms without interventions from support staff or natural supports.
Less than monthly: The applicant requires assistance with tasks, emotional support, reinforcement, and symptom monitoring from support staff or natural supports every few months but is otherwise independent. The screener may select this answer if the applicant has recently become independent with a skill but may need some follow-up to ensure task completion. Since applicants may have support needs that may be irregular, using an average over the course of a few months is best practice.
1 to 4 times a month: The applicant requires, on average, assistance with tasks, emotional support, reinforcement, and symptom monitoring at least one time per month. Since applicants may have support needs that may be irregular, using an average over the course of a few months is best practice.
More than one time per week: The applicant requires, on average, assistance with tasks, emotional support, reinforcement, and symptom monitoring more than once per week. Since applicants may have support needs that may be irregular, using an average over the course of a few months is best practice.

1.11 Impending discharge

When completing the screen with someone preparing for discharge from a mental health facility in the near future, complete the screen based on how the applicant is expected to function at home when they go home. This looking ahead is a normal part of discharge planning. For example, although the facility administers medications now, mark on the screen if the applicant will need help with medication administration after they go home. It will take additional time and talking with the individual, facility staff, family, etc., to get the most accurate picture of the applicant’s needs at home after discharge.