NURS 6512 Functional Assessments and Assessment Tools

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NURS 6512  Functional Assessments and Assessment Tools

NURS 6512  Functional Assessments and Assessment Tools

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What's Happening in This Module?
Module 2: Functional Assessments and Assessment Tools is a 2-week module, Weeks
2 and 3. In this module, you consider the impact of functional assessments, diversity,
and sensitivity in conducting health assessments. You also explore various assessment
tools and diagnostic tests that are used to gather information about patients’ conditions
and examine the validity and reliability of these tests and tools. Finally, you examine
assessment techniques, health risks and concerns, and recommendations for care
related to patient growth, weight, and nutrition.
What do I have to do?     When do I have to do it?
Review your Learning Resources. Days 1–7, Weeks 2 and 3

Discussion: Diversity and Health
Assessments

Post by Day 3 of Week 2, and respond to your
colleagues by Day 6 of Week 2.

Case Study Assignment: Assessment
Tools and Diagnostic Tests in Adults
and Children

Submit your Case Study Assignment by Day 6
of Week 3.

DCE: Health History Assessment

You are encouraged to work on your DCE
every week. However, this Assessment is not
due until Day 7 of Week 4.

Go to the Module's Content

Week 2: Functional

Functional Assessments for Long-Term
Services and Supports
Key Points
• Functional assessment tools are sets of questions about an applicant’s health conditions and
functional needs that state Medicaid programs use to determine functional eligibility for longterm services and supports (LTSS) and to create specific care plans for eligible individuals.
• The federal government does not require states to use a particular assessment tool to
determine eligibility or to develop a care plan.
• MACPAC’s analysis of states’ functional assessment tools shows that there are at least 124
tools currently in use. On average, states are using three different tools each, as they generally
use separate tools for different populations.
• States that use managed care plans to deliver LTSS either require plans to use a certain tool or
allow them to use a tool of their choosing. There is limited information about the tools used by
plans, in part because some of these tools are proprietary.
• Almost all states use at least one tool that they developed themselves, which we refer to as
homegrown tools. States report that the use of homegrown tools is driven largely by their
need for customized tools for their populations and their desire to incorporate stakeholder
input. Staff in states that use independently developed tools said those tools were easier to
implement than homegrown tools.
• Use of a single national tool or set of core questions about functional status would facilitate
analyses of LTSS use across states that would reflect the variation in beneficiary needs. Such
information could be used for multiple purposes, including development of benchmarks for
appropriate care, setting payment rates, and identifying strategies that promote better use of
state and federal resources.
• Moving to a national tool, however, would be burdensome for those states that have recently
invested in new tools, and there is currently no clear empirical or operational reason to pick
one existing tool over another.
• Given the rapid change in LTSS programs and work that the Centers for Medicare & Medicaid
Services is doing to test new approaches to functional assessment and electronic exchange
of care plans, the Commission does not advocate moving to a national tool at this time, but we
will continue to monitor developments in this area.
Report to Congress on Medicaid and CHIP 69
Chapter 4: Functional Assessments for Long-Term Services and Supports
CHAPTER 4:
Functional Assessments
for Long-Term Services
and Supports
Medicaid is the nation’s primary payer for long-term
services and supports (LTSS) for individuals with
physical and cognitive disabilities. These services
generally focus on helping people maintain (and
sometimes improve) their ability to perform basic
tasks of everyday life, such as bathing and dressing,
and skills needed for independent living, such as
preparing meals and managing money. In order for
individuals to receive Medicaid-covered LTSS, they
must be determined eligible based on two types of
criteria. First, they must meet financial eligibility
criteria, with income and assets consistent with statedefined thresholds.1
Second, they must meet statedefined functional eligibility criteria, which are based
on physical and cognitive abilities. To determine
whether an individual meets a state’s functional
eligibility criteria, also referred to as their level of care
criteria, states use functional assessment tools—
sets of questions that collect information on an
applicant’s health conditions and functional needs.
Such tools may also be used to develop a care plan of
specific services that an individual will receive upon
being determined eligible for coverage.
The federal government does not require
state Medicaid programs to use any particular
assessment tool to determine eligibility for
Medicaid-covered LTSS or to develop a care
plan. In states with managed long-term services
and supports (MLTSS) programs, care plans are
developed using either a state-selected tool or—
depending on state requirements—a tool chosen
by the managed care plan into which a beneficiary
is enrolled.2
MACPAC’s inventory of assessment
tools shows that there are, at a minimum, 124 tools
currently in use for eligibility determination and care
planning. MACPAC also found that only a few states
use the same tool across all their LTSS programs.
Methods for assessing functional status are of
interest to the Commission for three reasons. First,
a disproportionate share of Medicaid expenditures
are for LTSS users. In fiscal year (FY) 2012, 43.4
percent of Medicaid expenditures ($169.2 billion)
were spent on LTSS users, even though LTSS users
comprised only 6.2 percent (4.3 million) of Medicaid
beneficiaries (MACPAC 2015). Assessment of
functional status has a direct effect on eligibility
determination and the services that beneficiaries use.
Second, changes in the delivery system for LTSS
are highlighting the role of functional assessments.
Increasingly, LTSS are being provided in homes
and community-based settings rather than in
institutions. In FY 2013, for the first time in the
history of the Medicaid program, the proportion of
LTSS expenditures for home and community-based
services (HCBS) was greater than the proportion of
expenditures for institutional services (Eiken et al.
2015). The movement to HCBS has expanded the
breadth of services used to address individuals’
LTSS needs and keep them integrated in the
community. In addition, more states are establishing
MLTSS programs, and these call for decisions
about how managed care plans are to conduct care
planning and which assessment tools they use.
Third, the substantial costs associated with
providing LTSS raise concerns about whether
services are delivered in the most efficient manner.
This question, however, requires information about
costs relative to need. But because states use
such varied approaches to functional assessment,
it is not currently possible to compare LTSS needs
across populations in different states or compare
beneficiary access to services across states.
Comparable data on the needs of LTSS users
would also be useful in evaluating different LTSS
program designs and the relationship of payment
to services provided. Such information could shed
light on the quality of care provided to individuals
with LTSS needs, allow for inclusion of the severity
of LTSS needs in the development of payment
rates, highlight state innovations that are effective
and worthy of replication, and suggest potential
70 June 2016
Chapter 4: Functional Assessments for Long-Term Services and Supports
changes in federal policy to incentivize adoption of
effective approaches.
In this chapter, we describe how functional
assessment tools are currently being used across
states at the state and federal level. We begin by
describing how functional assessments are used
in eligibility determination and in care planning.
The chapter then focuses on federal guidance
affecting assessments and various federal
initiatives to support states in improving tools and
standardizing data elements.
Next, we present the results of new research
conducted for MACPAC that documents the wide
variation in functional assessment tools across
all 50 states and the District of Columbia. We
have documented the dozens of disparate tools
currently in use by state Medicaid programs as well
as the many ways states are measuring needs for
specific activities, such as bathing and dressing. Our
interviews with Medicaid program staff in different
states found that their decisions about creating a new
tool or using one that already exists are influenced in
part by their perceptions of the level of customization
needed and the ease of implementation. Finally,
we look at the advantages and disadvantages of
developing a national functional assessment tool or
using other means for making it possible to collect
more comparable assessment data across states.
Functional Eligibility Criteria:
Variation by Eligibility Pathway
Individuals must meet functional eligibility
criteria to receive Medicaid coverage for LTSS,
whether in an institution or the community. These
functional criteria vary by eligibility pathway
and by state, and the type of pathways that are
available to an individual depends on the state in
which they reside (Table 4-1). About two in five
Medicaid beneficiaries who received LTSS in FY
2010 enrolled through the Supplemental Security
Income (SSI) eligibility pathway (MACPAC 2014).3
In most states, individuals eligible for SSI are
automatically eligible for Medicaid, including—if
they meet functional eligibility criteria—LTSS
offered under the state plan. States also have an
option to provide Medicaid coverage to individuals
who have LTSS needs but whose incomes are too
high for them to be eligible through the SSI-related
pathway. States cover these individuals through
other eligibility pathways; some of these other
eligibility pathways use the SSI-related functional
eligibility criteria, and others use state-established
level of care criteria.
States have flexibility in determining the level of
functional impairment that will be used for each
of their eligibility pathways. A high threshold for
the level of care criteria might be requiring an
individual to be dependent in four or more activities
of daily living (ADLs), while a lower threshold might
require dependency in only two ADLs.4
Access
to most HCBS are based on having needs severe
enough for institutional care, but some states use
Section 1915(i) authority, which allows states to
offer services to individuals meeting less stringent
criteria.
Functional Assessment
Process: Eligibility
Determination and Care
Planning
Functional eligibility for Medicaid-covered LTSS
is determined using functional assessment tools.
Depending on the state, the entity responsible
for conducting the Medicaid eligibility functional
assessment may be the state or local health
department, an area agency on aging, an aging and
disability resource center, or a contracted vendor
(Tucker and Kelley 2011, Shirk 2009). The functional
assessment is typically conducted in a face-toface interview in the individual’s home, which helps
ensure that environmental issues, such as need for
home modifications, are addressed (Shirk 2009).
Report to Congress on Medicaid and CHIP 71
Chapter 4: Functional Assessments for Long-Term Services and Supports
TABLE 4-1. Medicaid Eligibility Pathways for Long-Term Services and Supports
Eligibility pathway
Age group served
Functional assessment
criteria
Receives full
state plan
benefits
Benefits conditional
upon LOC criteria
≥ 65 19–64 <19
Institutional
LTSS
HCBS
waiver
SSI-related
Yes Yes Yes
Adults ≥ 65: None;
Adults 18–64: Blindness

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or permanent, medically
determinable impairment
that results in the inability
to do any substantial
gainful activity Yes
NF: Yes;
All other
institutions at
state option
At state
option
Children < 18: Permanent,
medically determinable
impairment that results
in marked and severe
functional limitations
Children < 18: Yes, if
determined medically
necessary under EPSDT.
Poverty-related
Yes Yes Yes Same as SSI Yes
NF: Yes;
All other
institutions at
state option
At state
option
Medicaid
buy-in
BBA 97
eligibility No Yes 16–18
only Same as SSI Yes At state
option
At state
option
Basic
eligibility
group
No Yes 16–18
only Same as SSI Yes At state
option
At state
option
Medical
improvement
group
No Yes 16–18
only
Must have a medically
improved disability
(based on SSI disability
determination)
Yes At state
option
At state
option
Family
Opportunity
Act
No No Yes Same as SSI Yes At state
option
At state
option
Medically needy Yes Yes Yes Same as SSI At state
option
At state
option
At state
option
Special income rule Yes Yes Yes State-established LOC for
NF, ICF, or hospital Yes At state
option
At state
option
TEFRA/Katie Beckett No No Yes State-established LOC for
NF, ICF, or hospital Yes No At state
option
Section 1915(i) state plan
HCBS Yes Yes Yes State-established LOC less
than for NF, ICF, or hospital
At state
option No At state
option
Notes: LOC is level of care. LTSS is long-term services and supports. HCBS is home and community-based services. SSI is Supplemental
Security Income. NF is nursing facility. EPSDT is Early and Periodic Screening, Diagnostic, and Treatment. BBA 97 is the Balanced
Budget Act of 1997 (P.L. 105-33); this and other buy-in eligibly pathways allow states to cover individuals with disabilities who work and
have incomes too high to qualify for Medicaid. ICF is intermediate care facility. TEFRA is the Tax Equity and Fiscal Responsibility Act
(P.L. 97-248), the TEFRA/Katie Beckett pathway provides Medicaid eligibility to children with severe disabilities whose family income
would ordinarily be too high to qualify for Medicaid. For beneficiaries receiving institutional or HCBS waiver LTSS under any eligibility
pathway, states have an option to disregard parent or spousal income and to allow beneficiaries to retain income under personal needs
allowances or monthly maintenance needs allowances.
Sources: HRTW National Resource Center 2013, SSA 2013, Stone 2011.
72 June 2016
Chapter 4: Functional Assessments for Long-Term Services and Supports
If an individual is eligible for more than one LTSS
program, the state may require assessment with
multiple tools, which can be a time-consuming
process for the individual and assessors.
Once determined eligible for Medicaid, a care plan is
developed using either the eligibility determination
tool or a separate tool. For individuals whose LTSS
benefits are covered under fee for service, care plan
development and ongoing case management is
often assigned to care coordinators from the same
entities that conducted the eligibility determination.
Care coordinators are then responsible not only for
determining which services a Medicaid beneficiary
should receive and the frequency and duration of
those services, but also for connecting the beneficiary
to service providers. In states with MLTSS, care plans
are developed by care coordinators employed by
the managed care plan in which the beneficiary is
enrolled or by a third party contracted by the plans to
provide these services (Box 4-1).
Federal Role in Functional
Assessment
Federal requirements for functional
assessment tools
Federal laws and regulations do not require the use
of specific tools for either eligibility determination or
care planning, and they do not require the collection
BOX 4-1. Functional Assessments and Managed Long-Term Services
and Supports
The number of states with managed long-term services and supports (MLTSS) programs has risen
rapidly in recent years, growing from just 8 in 2004 to 22 in 2014 (Terzaghi 2015, Saucier et al. 2012).
Another 11 states are in the process of implementing or considering such programs (Terzaghi
2015). In MLTSS, states contract with managed care plans to provide long-term services and
supports (LTSS) to beneficiaries in exchange for a capitated payment. These plans are responsible
for providing the broad range of LTSS benefits within the capitated rate. In order to coordinate the
services beneficiaries receive, managed care plans may employ case managers directly or delegate
coordination to a third-party case management service. In either circumstance, case managers are
responsible for developing beneficiary care plans (with input from the beneficiaries, their family
members, other persons providing support, and providers), and also serve as the beneficiaries’ main
point of contact for dealing with issues such as scheduling transportation to and from medical
appointments and connecting to community resources and activities.
States that adopt MLTSS must make certain decisions about the use of assessment tools.
Some states (e.g., Minnesota and Texas) require all plans to use a certain tool, while others (e.g.,
Tennessee and Wisconsin) allow each plan to use the tool of its choosing, albeit with certain
requirements or restrictions (Ingram et al. 2013). Some plans develop proprietary tools, while
others may use tools available on the market. States may also require plans to collect specific data
elements and report those results to the state for purposes such as quality monitoring and the
setting of capitation rates (Atkins and Gage 2014). States also set other requirements for plans,
including specific timeframes for completion of assessments for new enrollees and reassessments
of existing beneficiaries, as well as qualifications and training requirements for the case managers
conducting assessments (Ingram et al. 2013).
Report to Congress on Medicaid and CHIP 73
Chapter 4: Functional Assessments for Long-Term Services and Supports
of specific data elements. Federal laws and
regulations do have the following requirements:
• The assessment to determine eligibility
for nursing facilities must be ordered and
provided under the direction of a physician
(42 CFR 440.40(a)).
• Nursing facilities must conduct comprehensive
assessments to determine each resident’s
functional capacity soon after admission and
no less than once every 12 months (more
often if there is a change in condition that
requires a new assessment in the interim),
and the assessment should be conducted or
coordinated by a registered professional nurse
(§ 1919(b)(3) of the Social Security Act).
• A physician must certify that an individual with
intellectual disabilities needs intermediate
care facility services (42 CFR 456.360).
• States that use the Community First Choice
Section 1915(k) state plan option must
use a person-centered care plan based on
an assessment of functional need (42 CFR
441.535).5
These states must also restrict
eligibility to cover only individuals who require
a level of care equivalent to that provided in an
institution (42 CFR 441.510(c)).
• HCBS waiver eligibility must be limited to
those who require a level of care equivalent to
that provided in an institution (§ 1902(a)(10)
(A)(ii)(VI) of the Social Security Act).
• In states with MLTSS, managed care plans
are required to comprehensively assess
beneficiaries’ LTSS needs and use personcentered care planning processes (42 CFR
438.208(c)). Sub-regulatory guidance further
specifies that states approve the tools a
managed care plan uses and that such tools
assess physical, psychosocial, and functional
needs (CMCS 2013).
By contrast, care planning assessments for nursing
facility residents are strictly prescribed: all nursing
facilities must use the same assessment tool, the
Minimum Data Set (MDS), for all residents.6
Similarly,
home health agencies delivering Medicare-covered
home health services are required to use a common
care planning assessment tool, the Outcome
and Assessment Information Set (OASIS)—this
requirement has been in place since 1999.
CMS functional assessment initiatives
Although requirements for functional assessment
tools are limited, the Centers for Medicare &
Medicaid Services (CMS) recently implemented two
initiatives to provide resources to states to make
changes to their existing tools.
The Balancing Incentive Program. The Balancing
Incentive Program, for which program funding
ended in 2015, was one of several recent initiatives
to expand Medicaid beneficiaries’ access to HCBS
and reduce state reliance on institutional care.7
Participating states earned an enhanced federal
match for the HCBS provided to beneficiaries
during the demonstration, and in turn were required
to implement certain structural changes in their
LTSS delivery systems. One of these structural
changes was the adoption of a standardized
functional assessment process and an instrument
or instruments to determine eligibility for Medicaidfunded LTSS if such tools were not already in use
(CMS 2016a). Further, these assessments had to
include a core set of domains related to medical
needs, ADLs, instrumental activities of daily living
(IADLs), and mental and behavioral health needs
(MAG and NEC 2015). However, CMS did not require
states to use any particular questions or a specific
tool if a state’s existing tools covered the specified
domains. Seven of the 18 participating states
needed only to add questions to their existing tools
to meet these requirements, and 4 of the states
met all of CMS’s requirements without making any
changes. In addition, seven states implemented an
entirely new tool during the program, although that
may have been for reasons other than ensuring
that the core domains were included (MAG and
NEC 2015).
74 June 2016
Chapter 4: Functional Assessments for Long-Term Services and Supports
States that implemented a new tool during the
program reported that the resources provided
by the Balancing Incentive Program eased the
implementation process. Some of these states
had planned to overhaul their existing tools prior
to their participation in the Balancing Incentive
Program and found that the additional resources
helped make that possible. For example, New
York noted that the resources provided by the
Balancing Incentive Program helped facilitate
the implementation of a tool that was already in
development (MAG and NEC 2016).
Testing Experience and Functional Tools
demonstration. CMS is currently developing a
set of assessment questions through the Testing
Experience and Functional Tools demonstration.
In March 2014, CMS awarded planning grants to
Medicaid programs in nine states as part of the
demonstration to test several tools related to LTSS
quality and assessments. Six of the participating
states (Arizona, Colorado, Connecticut, Georgia,
Kentucky, and Minnesota) will be testing the
Functional Assessment Standardized Items (FASI)
tool with a sample of their Medicaid beneficiaries
at the time of reassessment, sometimes alongside
their existing functional assessment tools. Field
testing is expected to begin in the second half
of 2016, with refinements and additional testing
planned through 2017 (CMS 2016b).
The FASI tool includes domains covering
identifying information, functional abilities and
goals, assistive devices, support needs, and
caregiver assistance. The tool is based on the
Continuity Assessment Record and Evaluation tool
used in Medicare post-acute care settings (e.g.,
long-term care hospitals, inpatient rehabilitation
facilities, skilled nursing facilities, and home health
agencies) and is being pilot tested as part of a
broad CMS effort to standardize assessment data
resulting from the Improving Medicare Post-Acute
Care Transformation Act of 2014 (IMPACT Act,
P.L. 113–185). The IMPACT Act requires CMS to
implement standardized assessment measures
for Medicare post-acute care settings to replace
certain setting-specific questions currently in use,
and eventually to develop a unified post-acute
care payment system. This effort arose in part
due to concerns raised by the Medicare Payment
Advisory Commission (MedPAC) and others that
Medicare patients with similar characteristics are
often served in different settings with different
payment rates (MedPAC 2015). Gathering similar
assessment information from all such providers
will increase understanding of the cost of care
across settings and the extent to which variation
in costs reflects local practice patterns, provider
availability, and other factors as opposed to
measurable differences in patients’ needs.
Once the FASI testing is completed, CMS plans
to make it available for use by state Medicaid
programs, providing access to a set of pretested
and validated data elements for use in functional
assessment. CMS may also consider additional
uses (Smith 2016). For example, it could potentially
be used to collect assessment information across
all states, an idea discussed later in this chapter.
The demonstration also includes the electronic
Long-Term Services and Supports (eLTSS)
Initiative, which is a joint effort between CMS
and the Office of the National Coordinator (ONC).
CMS and ONC are working to develop standards
for interoperable LTSS service plans, which would
include information from functional assessments
that could be shared among LTSS providers,
payers, and individuals receiving the services (ONC
and CMS 2016). Six states will be piloting this
component of the demonstration, which according
to CMS, could improve coordination

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