Appendix 114-E Assessment Instruments for Non-Medicaid Home and Community Based Services: Risk Assessment Tool (RAT) | HCBS-5300-MANUAL

Members of the statewide Case Management Redesign Work Team identified risk factors for institutionalization based on their extensive field experience. Then, DAS researchers from the Program Integrity and Access to Services Sections conducted research on known risk factors. Staff combined this knowledge into the Risk Assessment Tool (RAT). The section inclusion criteria are based on research-identified risk or topics deemed important but not found in research. Sections that research identified as not contributing risk were excluded. Where risk factors are identified in research, those questions in the RAT are appropriately weighted to calculate Risk Levels (High, Moderate, and Low).

Sections included in the RAT are:

Certain sections contain trigger questions linked to full vetted assessments that properly identify the individual’s risk in the category (e.g. Risk of Falls triggers the Stay Independent brochure). The Rosalynn Carter Institute for Caregiving (RCI), in partnership with Emory University’s Fuqua Center for Late-Life Depression and the Alzheimer’s Research Center, identified the trigger questions (and associated specialized assessment for the domains of cognitive impairment, caregiver burden, depression, and mental health.

Section A (DON-R Functional Status Scores) and Section B (DON-R Unmet Need Score) will auto populate from the latest DON-R assessment completed for that client.

Section D asks about prior unplanned hospital use. This does not include planned procedures and does include emergency room visits. There are two possible responses:

If prior visits are reported, inquire whether there were any re-hospitalizations within 30 days of discharge for the same condition. If so, consider a referral to your Care Transitions program.

Section E documents risk of falls using questions developed by the Centers for Disease Control and Prevention (CDC). Each of the three questions requires a “Yes” or “No” response. If any of the questions is answered “Yes”, the score adjusts to show increased risk.

Section F begins by asking whether the client has a medical diagnosis of cognitive impairment. This must be an actual diagnosis by a medical professional (Alzheimer’s disease, Lewy Body Disease, etc.), not a generic statement such as “doctor thinks she is confused.” If possible, document the information about the diagnosis in the case notes.

If the answer to this question is “Yes” the section automatically scores.

If the answer to this question is “No” then additional questions will display.

Read the script to the client and record his/her ability to repeat the five words during each of two trials.

Next, administer the two Oral Trailmaking Tests as described.

This sub section automatically scores.

The next section is administration of the delayed recall. Document each of the five words that the client remembers. Manually enter the number of correct responses in the “TOTAL RECALL” box. The system will compute the subscore and the total score for Section F.

The system calculates scoring based on number of seconds required to complete the tasks and the number of words recalled.

This section asks four questions about the client’s mental health over the past two weeks. The possible responses for each question are:

The section is broken into two sub-sections. Subscore 1 relates to anxiety and Subscore 2 relates to depression. Each is scored separately. If the Subscore1 total is 3 or greater, it is recommended that the GAD-7 be administered. If the Subscore2 total is 3 or greater, it is recommended that the PHQ-9 be administered.

The first question asks whether a caregiver is present. If not, skip this section. Part A gauges the caregiver’s intention to place the care receiver in a nursing home or other long-term care setting. Select the response provided by the caregiver. If the caregiver answers “Probably Would,” further assessment using the Bakas Caregiving Outcomes Scale (BCOS) may be helpful. Also, consider a referral to Community Options Counseling.

Part B is taken from the Zarit Burden Interview and asks four questions about the impact of providing care on the caregiver’s life.

If the Section H, Part B sub score equals 1, it is recommended that the caregiver be assessed using the Bakas Caregiving Outcomes Scale (BCOS).

This section asks four questions regarding use of alcohol and drugs (both legal and illegal). Each question requires a response of “Yes” or “No.” You should verify that the answers given in this section correspond to the question about “having 3 or more drinks” from the NSI.

If the total score equals 2 or greater, assess further using the AUDIT-10 assessment.

This section identifies risk of abuse, neglect, or exploitation. Identify whether there is an active case with Adult Protective Services (APS) and/or whether there is a history of involvement with APS.

This section identifies the level of social support available to the client. The section asks whether the client lives alone (compare to the NSI question about “eating alone most of the time”, the Level Impairment Score in the domain of Being Alone, and interpretation of unmet need scores), the client’s marital status, and whether the client has someone to contact when help is needed (and the identity of that person – be sure to include in the Contacts screen). The system automatically calculates the weighted score for this section based on the responses.

This section looks at risks posed by the client’s current living environment, and asks about home ownership. All questions require a response of “Yes” or “No.” If risks are identified, consider conducting a home safety assessment.

This section documents the degree of access the client has to services, including transportation, whether the client lives in a rural area, the safety of the client’s neighborhood, and whether the client has access to income and/or resources to afford services (compare this information to the Income Worksheet). For question 3, the concerns can be voiced by the client or the caregiver, or can be based on the objective observations of the assessor.

The demographic section auto populates from the Demographics tab and calculates the weighted score. If the information in this section is not correct, make the changes on the Demographics tab as well as within Section N.