114 Guidelines for Client Assessment | HCBS-5300-MANUAL

This chapter establishes the guidelines for quality service and accountability for Area Agencies on Aging (AAAs), Area Agency contractors, and subcontracting service providers when conducting client assessments for non-Medicaid Home and Community Based Services (HCBS).

This chapter also establishes the guidelines for using specified assessment instruments during both telephonic assessment and face-to-face assessment.

Client assessment encompasses those activities that directly relate to telephone assessment and periodic reassessment of persons by the Area Agency on Aging through its Aging and Disability Resource Connection (ADRC) program. Client assessment also encompasses those activities that directly relate to face-to-face assessment and periodic reassessment of persons by the AAA through a designated case management organization or its provider network.

These standards provide guidance to AAAs in achieving the following goals:

The purpose of assessment is to document the capacities, needs, and functioning of the consumer in a holistic approach that results in a Care Plan tailored to that consumer. We never assess for a specific service.

The primary objectives of initial face-to-face assessments are to expand upon the information obtained at telephone assessment including functional impairment level, unmet need for care, level of nutrition risk, and other various individual needs of a consumer for services, and to obtain a more thorough evaluation of eligibility, when appropriate.

The goal is the development of an individualized Care Plan in collaboration with the consumer and caregivers when present, through which care needs will be met by one or more service providers and/or other community resources, including those resources within the consumer’s support network.

The primary objective of periodic reassessment is to review all criteria related to initial and subsequent reassessment findings, so that any necessary adjustments in service planning and delivery may be made, based on the client’s most recent status and situation.

The Older Americans Act states that persons are eligible for Older Americans Act services at age 60, with additional criteria for recipients of Title III-C and Title III-E services.

If funds are not enough to serve all persons who are eligible based on age requirements, the Older Americans Act (see References) requires that services are provided with particular attention to targeted populations including but not limited to:

AAAs will ensure that limited resources are used to serve older adults, persons with disabilities and their caregivers in greatest need based on assessment information and based on ongoing information obtained through periodic utilization review and/or reassessment (see Appendix 114-H and Appendix 114-I) and through information and observation provided by both formal and informal service providers. See MAN 5300, 118 Prioritizing Clients for additional information.

Following AAA telephone triage, and subject to the availability of services, the AAA will refer clients in need of HCBS services to appropriate providers (CMO or provider agency) for a comprehensive initial face-to-face assessment.

In instances deemed to be an emergency, AAAs may refer clients to appropriate providers and authorize them to begin services prior to the completion of an initial face-to-face assessment.

Either the Case Management Organization (CMO) or the provider will complete the initial face-to-face assessment within ten calendar days of service initiation. AAAs that exercise this option must assure that providers adjust services to appropriate levels based on the face-to-face assessment. The AAA will establish protocols to ensure that providers do not accept clients who are found to be inappropriate for any reason for the original service requested and will work with providers to ensure such consumers are referred to appropriate resources.

The Division approaches the process of assessment and reassessment in a holistic manner, seeking to identify client needs and resources across a spectrum of domains. Specific domains to be assessed are described in Appendix 114-A Domains of Comprehensive Assessment.

The Division will periodically review the need to establish additional assessment domains, instruments, and data sets. Refer to the Appendices at the end of this chapter for an overview of the various assessments.

Because assessments track consumer changes over time and are the foundation of ensuring appropriateness and effectiveness of services, staff must not copy assessment scoring, comments, or notes between subsequent assessments.

If the consumer is identified to be in need of services based on his/her relationship as a caregiver to another eligible consumer, priority will be based on the level of caregiver burden, using the Bakas Caregiving Outcomes Scale (BCOS). To receive caregiver services, the caregiver must be present/available to provide periodic or ongoing care, and the AAA must document that the caregiver will likely benefit from the services to be provided. Staff may assess the care receiver (using the DON-R, RAT, etc.) to help determine appropriate interventions.

Numerous funds sources may be used to provide caregiver services; however, the caregiver MUST be the identified client.

Each AAA will implement a process to ensure that variations in DON-R scores between ADRC and the face-to-face assessment that exceed ten points, as well as any other factors that may impact eligibility determination or redetermination, are communicated back to ADRC.

Follow-up. The AAA will designate appropriate staff to provide telephone follow up with clients/caregivers no later than the end of the first sixty (60) calendar days of service delivery to determine the degree of client/caregiver satisfaction with services and whether the services are meeting the needs identified by the assessment process. The designated staff should support the AAA’s conflict-free system (See §114.14).

During the 60-day follow-up staff should identify whether the level of impairment or unmet need for care has changed in the relevant domains for which services were initiated. Staff should re-administer the DON-R during this follow-up. It is not necessary for staff to enter comments for domains in which no changes have been detected but comments are required for domains in which a change has occurred.

Redeterminations of client status and service delivery are to be completed within specified time frames based on the Level of Risk identified by the RAT, either 6 months, 12 months, or 18 months; or if the RAT is not required by the AAA, no less than annually. This utilization review should include re-administration of the DON-R, NSI, Food Security, RAT, and specialized assessments as indicated.

AAAs will identify in their Area Plan documents whether the function of utilization review is managed through the ADRC system, through case management, a combination of the two, or an alternate method. If an alternate method is chosen, the AAA must explain in its Area Plan how the process is handled independently of the provider of services.

During the utilization review process, the level of services a client receives may remain the same or may be increased, decreased, or terminated based on the information obtained. Changes that result in modifications to service levels will be thoroughly documented in the client’s record and clients will be notified of their right to appeal decisions about service levels (see MAN 5300, §202.5D).

Designated staff will conduct reassessment in accordance with the consumer’s individual RAT score (or, if the RAT is not required by the AAA, no less than annually) or whenever there is a significant change in client condition, status, or circumstances that would affect the need for a change in service levels and/or additional services to be provided. Consumers receiving comprehensive case management services may be reassessed at the time of Service Plan reviews, as determined by the case manager.

To better coordinate the assessment functions among multiple providers, DAS recommends the following order:

The DON-R, NSI, and Food Security Survey are to be completed at the following events:

Optional specialized assessment instruments are also to be used as needed and indicated by the client’s basic assessments and/or the professional judgment of service providers.

Unless otherwise specified in program policy, service plans and service plan reviews (when required) should coincide with periodic reassessments.

The initial face-to-face assessment must be completed within ten business days of receipt of referral for service from ADRC. Exceptions to this standard are to be fully documented in the client’s case notes. However, in no instance shall the initial attempt to contact the client to schedule the face-to-face assessment exceed two business days.

Primary Assessment: When a client receives both non-Medicaid HCBS and Community Care Service Program (CCSP) services, the CCSP assessment and resulting care plans are primary and must incorporate and reflect the non-Medicaid services. Non-Medicaid HCBS providers have no further responsibility under these policies for assessment/service planning in those cases but will communicate and work with the Care Coordination Agency regarding need for adjustments in service levels and care plans based on their observations over the course of providing services. (Note: Non-Medicaid HCBS providers that are licensed by the State Healthcare Facility Regulation (HFR) Division of the Department of Community Health as private home care providers may have additional requirements for assessment pursuant to those regulations.)

Electronic client records and reporting: To comply with federal and state reporting requirements, AAAs or other designated entities will continue to enter any additional client data required for non-Medicaid services into the DAS data system to document and report each non-Medicaid service provided.

AAAs shall establish protocols and procedures for obtaining from the CMO/provider necessary data from the assessment/care plan information.

The Area Agency shall assure that initial and ongoing client assessments are conducted in a manner that provides maximum coordination and integration with its intake, assessment, and information and assistance processes and with ongoing case management and service delivery, at whatever level that activity occurs.

The Area Agency may, through the negotiation of subcontracts, delegate any or all components of client assessment activities.

AAAs shall develop protocols by which clients served by more than one organization do not receive duplicate assessments, and that services provided by several providers are coordinated through a single plan of care. AAAs shall negotiate with contract providers to designate a “lead agency” to coordinate care and services when there are multiple HCBS providers involved with a client.

AAAs are to assure that only one assessment per client per assessment interval and that only one redetermination of eligibility per eligibility interval occurs and is recorded in the DAS data system, except as noted here.

Information about both caregivers and care receivers must be indicated and recorded for the Title III-E National Family Caregiver Support Program, depending on the mix of services provided.

The Division may request documentation at the time of submission of a proposed Area Plan, Area Plan amendment or update; at the time of a program review or quality assurance review; or at any other time the information is needed as a part of program evaluation.

Optimally, assessment is conflict-free; that is, performed independently by appropriately trained personnel who are not employed by an organization that also contracts with the AAA to provide supportive and other services.

In an optimal system, the AAA utilizes an objective, third-party entity (including the AAA) that provides initial face-to-face assessment and periodic reassessment for those persons deemed appropriate to receive home and community-based services, either on a short-term or long-term basis. The assessment of potential clients and service planning on their behalf is separate from the provision of services.

The AAA will document in its Area Plan (beginning with the SFY 2018 Area Plan documents) its participation in a conflict-free assessment and service delivery system.

If enough resources are not available to implement the optimal system described above, the AAA will ensure use of reasonable firewalls to mitigate conflict between assessment or reassessment and service delivery, including but not limited to:

Providers shall assure that they will not accept clients for whom their services are inappropriate, based on the completed assessment. The AAA will work with providers to establish protocols for having inappropriate referrals re-assessed and referred to appropriate resources.

Area Agencies shall assure that staff performing assessments, at either the AAA or subcontract agency level, are competent, ethical, sufficient in number and qualified by training and/or experience to conduct client and caregiver assessments using the assessments, tools, and data collection/management systems specified by the Division. Staff conducting assessments shall have specialized knowledge of older persons, with particular strength in assessing the variables that affect health and functioning.

Area Agencies are responsible for identifying training needs of both AAA and provider staff and notifying appropriate Division staff if they need technical assistance or assistance with providing training.

For individuals being referred for initial face-to-face assessment for HCBS services who are also active on the CCSP waiting list, the provider worker conducting the assessment must meet any education and experience requirements outlined in CCSP policy and must demonstrate competence administering the DON-R. The AAA may choose to complete the initial face-to-face assessment in lieu of the HCBS provider to meet CCSP policy standards.

The entity conducting consumer assessments shall establish for each participant a confidential record in a form designated or authorized by the Division, that is protected from damage, theft, and unauthorized inspection, and that is made available for monitoring and audit purposes.

The record shall contain, at a minimum, the following information in form and format provided by or approved by the Division:

The AAA shall develop and implement written procedures to be followed by staff performing assessments at any level to obtain and document the consent of the consumer for the release of confidential information to other providers when referrals are made.

To ensure consistency and competence in administering assessments, staff must complete required trainings, either online or in person. The AAA must have policy related to any method of completing assessments other than directly into the DAS data system. The AAA must develop written policy to ensure that staff completing assessments on paper have received training in and are competent to administer them regardless of who enters the information into the DAS data system. Contact Division staff if training is needed.

When staff discover conditions during the assessment that warrant referral, they shall assist consumers in taking advantage of other services, whether provided through the aging network or through other community, public, private, or fee-for-service agencies. Staff shall document such referrals in the consumer record, and the assistance or services obtained in the care plan, if of an ongoing nature.

AAAs/subcontractors shall maintain in the manner prescribed by the Division any such records, in addition to consumer records, as may be necessary for overall program management and report in compliance with the Division’s policies and procedures. Refer to MAN 5600 §1061 and MAN 5300 §202.5.

The Area Agency shall conduct periodic (at least annual) reviews of documentation in consumer records of the appropriate use of assessment tools used at the ADRC and may conduct such reviews in tandem with monitoring of the ADRC service. The AAA must select and monitor a reasonable and meaningful sampling of client records that is sufficient in number to ensure compliance with this policy.

The Area Agency shall also conduct periodic (at least annual) reviews of documentation in client records of the appropriate use of assessment tools used by all service providers and may conduct such reviews in tandem with monitoring of the service provider.

The Division may monitor client assessment records at the AAA and subcontract provider levels to assure compliance with all applicable requirements.

The AAA shall periodically, but not less than annually, evaluate the effectiveness of client assessment and of determination and redetermination of eligibility activities (if provided as a stand-alone activity, not as a part of comprehensive case management), to determine the degree of accuracy of assessment and re activities and the degree of correlation of care plans to assessment data (including self-review procedures, if applicable). The AAA shall determine the degree to which the assessment component of case management contributes to the development of care plans which support maintenance or improvement of client status. The AAA will arrange for or provide training and technical assistance, when indicated, to improve assessment results.

Older Americans Act Sec 305(2) (E) “preference will be given to providing services to older individuals with greatest economic need and older individuals with greatest social need (with particular attention to low-income older individuals, including low-income minority older individuals, older individuals with limited English proficiency, and older individuals residing in rural areas.”

DON-R:

Hagopian M, Paveza GJ, Prohaska T, Cohen D: Determination of Need – Revision Final Report, Volume III. Chicago, Illinois: University of Illinois at Chicago, 1990.

Paveza GJ, Cohen D, Hagopian M, Prohaska T, Blaser CJ, Brauner D: A Brief Assessment Tool for Determining Eligibility and Need for Community Based Long Term Care Services. Behavior, Health and Aging 1: 121-132, 1990a.

Paveza GJ, Prohaska T, Hagopian M, Cohen D: Determination of Need – Revision: Final Report, Volume I. Chicago, Illinois: University of Illinois at Chicago, 1989.

Prohaska T, Hagopian M, Cohen D, Paveza GJ: Determination of Need – Revision Final Report, Volume II. Chicago, Illinois: University of Illinois at Chicago, 1989.

Determination of Need, Service Cost Maximum Study, Illinois Department of Aging, 2009.

NSI:

National Institutes of Health, “Nutrition and Health Risks in the Elderly: The Nutrition Screening Initiative”. www.ncbi.nlm.nih.gov/pmc/articles/PMC1694757/pdf/amjph00531-0046.pdf

The National Resource Center on Nutrition & Aging, “Nutrition Screening Initiative Checklist”

FOOD SECURITY SURVEY:

www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/survey-tools.aspx#six