118 Prioritizing Clients | HCBS-5300-MANUAL

While all adults aged 60 and over are eligible for services (except as noted in MAN 5300, CH 202.4A), the Older Americans Act Title III requires programs to prioritize service or give preference to older individuals with the greatest economic and social need, to persons who are frail, and to persons who are at risk of institutionalization. The OAA also identifies as a priority population persons with Alzheimer’s disease and related disorders and the caregivers of such individuals. Further, the OAA instructs that particular attention should be given to low-income older individuals, including low-income minority older individuals, older individuals with limited English proficiency, and older individuals residing in rural areas.

The ability to effectively target higher-priority persons is particularly critical when available funding is not sufficient to serve all persons who are eligible. In addition to providing guidance for remediating funding reductions, this document provides guidance in the prioritizing services to persons in greatest need.

The following definitions are taken directly or derived from language in the Older Americans Act.

The Aging and Disability Resource Connection in each AAA is charged with screening consumers for eligibility for various services. If a consumer meets age requirements, and funding is not sufficient to serve all eligible consumers, staff will use the four Older Americans Act target criteria to prioritize consumers for further assessment and care planning.

The Triage screening tool is based on the OAA target criteria, and specific questions are weighted using research that documents risk of institutionalization based on these factors.

Clients who are determined to be of higher priority are then referred for assessment and care planning to determine appropriate services and service levels. See MAN 5300, 202 Program Guidelines and Requirements and MAN 5300, 114 Guidelines for Client Assessment.

If the prioritization is due to a reduction in funding, the AAA should evaluate affected services first. If the funding reduction is not specific to a service area (example: Title III-C2) the AAA may identify which service or services to evaluate first; for example, congregate meals or homemaker services. DAS data system reports and the Area Plan documents may give some guidance about these services. Once the services are identified, the AAA may then prioritize the order in which the services will be reviewed, remembering that some clients may receive multiple services.

To ensure that assessments are completed accurately and appropriately, the AAA may require additional training for agency and/or provider staff who will be involved in this process. This training may include use of the DON-R, the NSI, Food Security Survey, as well as any other assessment tools used by the AAA, and/or specific issues of service eligibility or delivery. DAS suggests that such training be scheduled prior to initiating client reviews.

If the prioritization is due to a reduction in funding, the AAA should evaluate affected services first. If the funding reduction is not specific to a service area (example: Title III-C2) the AAA may identify which service or services to evaluate first; for example, congregate meals or homemaker services. DAS data system reports and the Area Plan documents may give some guidance about these services. Once the services are identified, the AAA may then prioritize the order in which the services will be reviewed, remembering that some clients may receive multiple services.

To ensure that assessments are completed accurately and appropriately, the AAA may require additional training for agency and/or provider staff who will be involved in this process. This training may include use of the DON-R, the NSI, Food Security Survey, as well as any other assessment tools used by the AAA, and/or specific issues of service eligibility or delivery. DAS suggests that such training be scheduled prior to initiating client reviews.

Start with clients with lowest total DON-R scores. Reviewing the following data from the client records will assist with prioritizing clients for whom a reduction in services or discharge may be appropriate.

Identify any policy guidelines that will influence services or service levels (for example, for Title III-E services the caregiver is the identified client and may have a lower DON-R score). Is the client a caregiver? If so, is there a care receiver identified? Do services align with policy?

Identify whether the client is on the waiting list for other service(s).

Identify any other service(s) that the client is receiving. Do those services accurately correspond to the DON-R score? For example, the client’s Level of Impairment score is a “1” in Bathing but is only receiving Home Delivered Meals.

Finally, review information in the client record that documents whether he/she is in greatest economic need and/or greatest social need. These factors must be considered in addition to assessment details in determining prioritization.

Review the case notes in the client’s record, with attention to the following questions:

The above steps will identify clients who are appropriate for continuing services at current levels and will also identify clients who should be considered for adjustments in the type or frequency of service(s).

For each client identified for reductions or termination of service(s), the AAA must complete a desk audit. This may be done by AAA staff or delegated to a contracted service provider. The person performing the desk audit must be trained in assessment protocols and DAS policy regarding service delivery.

If the desk audit results in questions or concerns for any client, the AAA must ensure that a thorough reassessment is completed, either by telephone or in person before a decision is made about that client’s service(s).

If the assessment indicates that current service levels are appropriate, update the Service Plan/Order for the client, or include a case note indicating that current service levels should continue.

Always ensure that services and service levels align to specific domains of the DON-R and with other specialized assessments completed.

If the assessment indicates that any current service(s) is not needed, or that a reduction in any current service(s) is appropriate, follow DAS policy to notify client as described in 202 Program Guidelines and Requirements.

Clients identified for reduction or discharge for services must be offered the option to receive service(s) on a private-pay basis, funded by the client, the client’s family, or other resources available to the client.

Specific strategies for serving clients based on an increase in funds can depend on several factors, including the amount of the increase and the timing of the increase. The following guidance is provided to promote the most effective use of these funds to serve highest priority clients. Any increase in service or service level should correspond to current assessments and service plans.

MAN 5300, Chapter 202

MAN 5300, Section 3016

Gaugler, Joseph E., Duval, Sue, et. al. “Predicting nursing home admission in the U.S: a meta-analysis,” BMC Geriatrics 2007, 7:13.Published June 19, 2007.

“Older Americans Act: Options to Better Target Need and Improve Equity.” U.S. Government Accountability Office, November 2012.

“Older Americans Act: Updated Information on Unmet Need for Services.” U.S. Government Accountability Office, June 10, 2015.

“Older Americans Act: More Should Be Done to Measure the Extent of Unmet Need for Services.” U.S. Government Accountability Office, February 2011.