Module #1: Overview of the Children's Long-Term Support Functional Screen (CLTS FS)Contents1.1 Introduction 1.1 IntroductionThe Wisconsin Children's Long-Term Support Functional Screen (CLTS FS) was developed by a Department of Health Services (DHS) workgroup in 2001 - 2003, as part of the Wisconsin's Children's Long-Term Support Redesign project. The goal of the redesign project was to improve access, coordination, choice, quality, and financing of the long-term support system to better serve children and families. The CLTS FS was built upon the success of Wisconsin's Long-Term Care Functional Screen (LTC FS) for adults. The LTC FS now provides eligibility determinations and specific levels of care (explained below) for all of Wisconsin's adults with long-term needs (frail elders and people with physical and developmental disabilities). Based on testing from 2003-2005, the CLTS FS has proven extremely accurate and reliable. Beginning April 1, 2005, the CLTS FS now provides functional eligibility determinations for six programmatic areas, multiple levels of care and target groups for children from birth through 21 years of age. For more information related to the screen's reliability and validity, training to become a certified screeners, and reference materials for certified screeners, see http://dhs.wisconsin.gov/LTCare/FunctionalScreen. The CLTS FS shares a secure web-based infrastructure as the LTC FS, and adult Mental Health screen, however, the CLTS FS functions independently of these screens and is more complex because:
The CLTS FS has been designed, operated, evaluated and improved through a rigorous quality management system. The CLTS FS was designed with skilled clinicians from each of the programmatic areas, as well as others with experience related to child development. The initial success of the screen is attributed to the willingness of program staff, as well as county agency partners, to build and test the screen throughout its development. Extensive validity testing and inter-rater reliability testing was completed with these state and county partners. The testing results demonstrate that the screen provides accurate functional eligibility results across multiple levels of care as well as six programmatic areas. Although the testing of the CLTS FS is complete, there is a "safety net" established to ensure that no child and family are wrongfully denied eligibility. State staff continue to: address screen questions, review questionable functional eligibility results, provide ongoing quality oversight, develop screen changes, develop clear written instructions, provide comprehensive training to new screeners, support for certified screeners and notify screeners of changes or improvements to the screen in order to maintain a high level of validity and reliability. Maintenance and improvement of the functional screen is an interactive process. Continuous quality improvement includes ongoing discovery activities including random reviews of individual children's screens related to accuracy and documentation related to the screener's responses, an analysis of individual screens and data, for example comparing screen functional eligibility to previous functional eligibility determinations, as well as trend and aggregate data to determine if screen results remain consistent and reliable. These efforts assure that screen issues are identified and corrected in a timely manner. The components of the CLTS FS are as follows:
The CLTS FS also includes information on risk factors, current and preferred living situations, and other factors. These other factors have been added to track critical national outcome data in areas such as the child's status with a primary health care provider (a Medical Home) and Transition planning services and supports. The screen also gathers data to facilitate disability determinations as are required for a number of programmatic eligibility criteria. The CLTS FS provides the opportunity for certified screeners to describe the needs of children with long-term support needs living at home, in substitute care settings, or in institutions as these factors relate to functional eligibility required for various children's long-term support programs. The following are the "screen development criteria" that guided these decisions:
[Back to Top] The CLTS FS determines functional eligibility for people from birth to age 21 years inclusive, and where relevant, a specific "Level of Care," and Target Group (explained below) for six different programs:
The Centers for Medicare and Medicaid Services (CMS) requires that "Target Groups" not be combined within one waiver. Therefore, there are three complimentary CLTS waivers (Developmental Disabilities, Physical Disabilities, and Mental Health). The screener will collect relevant functional eligibility information in the course of meeting a child and their family. Again, the CLTS FS is not a comprehensive assessment; rather it is a review of key information related to functional eligibility. Once the CLTS FS fields are complete, the computer functional eligibility logic is able to determine Hospital (HOS), Psychiatric Hospital (SED), Nursing Home (NH), and Developmental Disability (DD) Level of Care (LOC) for both Medicaid Home and Community-Based Services Waivers and the Katie Beckett Medicaid Program. Additionally, the related Target Group(s): Physical Disability, Mental Health or Developmental Disability, for the Home and Community-Based Services Waivers is determined. The CLTS FS will also provide a functional eligibility determination for the Family Support Program, Comprehensive Community Services, Community Options Program, and Mental Health Wraparound. The screener does not need to select program(s) for which they want to determine functional eligibility. The screen automatically reviews the child's functioning in comparison to functional eligibility criteria for all programs. Functional eligibility results may show that a particular child meets functional eligibility for some programs but not functional eligibility for other programs. The CLTS FS does not determine program eligibility, only one piece of program eligibility (functional eligibility). If functional eligibility results do not seem appropriate to the screener, or if the screener have any questions, the screener must let the CLTS FS Clinical Advisor know. This is critical to the accuracy and reliability of each Functional Screen. For young adults 18 years and up, the adult functional screen should be used to determine functional eligibility for CIP. For other programs that provide support to young adults ages from 18-22 years of age, the screener should select the screen that best matches the types of services the person is seeking from the waiver. For example, if the services are primarily adult programs, then use the adult functional screen. The Functional Screen tools are intended to streamline initial and ongoing functional eligibility determinations and to reduce duplicative efforts. Therefore, when a person is within the transitional ages of 18 to 22 years of age, programs will accept the results from the most appropriate functional screen. For example if a person is 19 years old and using one of the Medicaid CLTS Waivers, then the CLTS FS should be used for this as well as other programs such as COP and FSP. If another 19 year old is using the Medicaid CIP Waiver, then the adult LTC FS should be completed and these results will serve as results for COP and FSP. Social Security Disability Determination A child must also have a Social Security determination of disability for Katie Beckett Medicaid Program and most Medicaid Home and Community-Based Waivers eligibility. If a child has a confirmed disability determination the CLTS FS will issue actual functional eligibility results. If the child has not had such a determination, or if their disability status is unknown, the screen will display "pending a disability determination" on the eligibility results page. Eventually, parts of this disability process will be included in the screen; however, this area is still in the development and testing stage. 1.3 Other Functions of the CLTS FSThe CLTS FS gathers and stores all information collected in the functional screen process. These data serve multiple purposes beyond an individual child's determination for program functional eligibility. The data also:
1.4 Process for Transferring a Functional ScreenThe CLTS FS improves access to long-term supports for families by reducing multiple applications and eligibility reviews in order to access long-term supports and services. In addition to the benefits of this simplification for families is the reduction of duplication of effort by professionals at the state and county level. Central to this process is the acceptance of another certified screener's results for a child. Each certified screener has specific security and access rights. Therefore, a transfer process is needed to provide access to a certified screener in a different agency with differing security access. The functional screen is a protected health record under HIPAA (the Federal Health Insurance Portability and Accountability Act). Transferring screens between agencies must be done in compliance with federal confidentiality and security rules and requirements. 1.) When requesting a screen be transferred:
2.) When transferring a screen:
Once a screen is transferred, it cannot be revoked. If a screener transfers a screen to the wrong agency, only the agency that received the screen can transfer it back to your agency. It is not acceptable to ask the agency that incorrectly received the transferred screen to forward or transfer the screen to the correct agency. The agency that incorrectly received the screen must transfer the screen back to the agency that originally transferred the screen. For instructions on how to transfer a functional screen, refer to the
technical assistance document on our website at: http://dhs.wisconsin.gov/LTCare/FunctionalScreen/training.htm.
If you need help transferring a screen, contact the SOS Help Desk at: 3.) What the person receiving the functional screen will do: The person receiving the screen must check that the correct child's screen was transferred as well as the completion date for the most recent Functional Screen.
When you EDIT a screen, the screener must change a number of items on
the CLTS Functional Screen, in addition to the items being edited,
including: If the child has aged into a new age group for the ADL/IADLs and Social
Skills questions, be prepared to answer those
questions accordingly before selecting CALCULATE ELIGIBILITY. The screener
needs to recalculate eligibility when done editing the screen so that the
information can be considered in the child's functional eligibility
results. 1.5 Requirements for Quality Assurance and Screener QualificationsAs discussed above, the CLTS FS determines a child's functional eligibility for Wisconsin's long-term support programs, including:
Special requirements for quality assurance and screener qualifications
are necessary because the CLTS FS helps determine functional eligibility.
The screener must have experience regarding the unique conditions,
development, needs, and functioning of children with significant
disabilities. The screener must also complete training to be a certified
screener, as well as on-going review of their reliability as a screener.
1.6 Screen QualityParallel to the screener qualification, training, and certification requirements stated above, there are quality performance and assurance requirements to ensure consistency and accuracy of administration of the screen. There are three levels of CLTS FS quality assurance. 1. Individual Screener Quality Assurance Review. It is the screener's responsibility to be objective in screening, to be informed of the instructions, and to corroborate information gathered from the child's family. The State Clinical Staff can address questions that arise as a screener completes an individual child's CLTS FS. Screeners should contact the State Clinical Staff whenever they obtain a different result than expected for a child this includes functional eligibility and non-eligible results, as well as any discrepancy in the expected target group or level of care. Screeners should also seek clinical consultation on any individual screen question that is complex or confusing for a given child's circumstances. Screeners are held accountable for their results if they do not seek consultation under the circumstances noted above. This could result in a disallowance of state or federal funding and resulting recoupments. 2. Agency Level Quality Assurance Review. Agencies are held accountable for the accuracy of all screens completed by their staff. Inaccurate screens or screens manipulated for a particular outcome may result in a disallowance of state or federal funding and resulting recoupments. The methods each agency will be conducting will, at a minimum, include:
3. State Level Quality Assurance Review. The Department of
Health Services reviews screens and utilizes quality assurance
methods during quarterly and annual reviews. This includes a series of
analyses and comparisons of all agencies' screens. Each agency will
receive a report following such reviews, including a request to the
screening agency to correct and amend any screen errors or
inconsistencies. 1.7 The CLTS FS is Required for Long-Term Support Functional Eligibility DeterminationsParent(s) should provide informed consent to participate in providing information for a functional screen functional eligibility determination. This includes the requirement that all information provided must be accurate and truthful and that failure to be accurate and truthful has consequences. The parent(s) may refuse to provide needed information and may refuse to have a CLTS Functional Screen completed. However, the consequence of this decision is that the child may not be able to access Medicaid and long-term support services. The parent(s) should also be informed that information gathered during the screening process is confidential, and that information will be submitted to DHS for aggregate data analyses and may have an affect on their functional eligibility or ineligibility for other programs. No screen should be completed without the parent(s) consent. Screening agencies shall comply with confidentiality and Health
Information Privacy Protection Act (HIPPA) rules and requirements, and
shall obtain a signed release of information from the child's parent(s) or
guardian(s) for the use of medical records, educational records and other
records as appropriate before conducting the CLTS FS. Signed releases of
information shall be included in the child's records when appropriate. 1.8 ConfidentialityAny information collected for the screen or during the screening process is confidential. Information is to be treated with the same requirements for confidentiality within the current system of long-term supports. If one agency completes the screen but the family wants the results to be considered by another relevant long-term support system, separate consent to share confidential information may be required. Example: A family contacts the Family Support Program to apply for these supports and services. In the course of completing the screen, it appears that the child will also be COP and Medicaid Home and Community-Based Services Waiver eligible. The CLTS FS information can be shared between members of the same agency on a need-to-know basis. However, if the lead agency for COP or the Waiver is different, a release of information will need to be obtained from the family before access to CLTS FS information is granted to a different agency. All information can be viewed at the state level on a need-to-know
basis. This includes quality management activities at an individual and
aggregate level. As part of the initial consent process, parent(s) will be
informed that information entered into the screen will be entered into a
state level system. However, these results will only be viewed at an
individual level when there is a need-to-know. For example, the screen
completed by a Family Support Program is entered into the CLTS FS. The
functional eligibility results indicate that the child is likely to be
eligible for the Katie Beckett Program. The Family Support Program could
refer the family to their regional Katie Beckett Consultant or, with
proper consent, could notify the regional Katie Beckett Consultant that
the family has a desire to have a Katie Beckett eligibility determination
made for their child. 1.9 Screening and Re-Screening RequirementsThe Medicaid Home and Community-Based Services Waiver, the Katie Beckett Medicaid Eligibility Program and the Family Support Program require an initial screen to establish functional eligibility prior to receiving services. An annual re-screen, or recertification, is required thereafter to ensure continued functional eligibility. It is critical, whenever the condition of a child enrolled in a long-term support program substantially changes, that the CLTS FS be updated and the functional eligibility logic re-run. This will determine whether or not the child's change in condition impacts their level of care, target group or functional eligibility by program. The CLTS FS can be done more often than yearly. This includes whenever
a screen is transferred, the child's condition changes or other important
changes need to be documented. It is important that when re-screens are
done, that the screener review the child's previously completed screens
for information and historical perspective. The data warehouse maintains
all information from previously calculated screens so that the
longitudinal perspective is preserved when a new version of the screen is
created. 1.10 The Screening and Interview ProcessThe screening process requires face-to-face contact with the child being screened. Ideally, the required face-to-face interview should take place in the family's home with the child present. This home-based visit is required if the family is applying for the Katie Beckett Program. It may take more than one contact with the child and parents to complete the CLTS FS. There is a paper version of the Functional Screen. This is intended as a reference tool only. The paper version is not intended as an interview guide or application form for families. Certified screeners may use existing agency application and assessment forms to assist them in collecting necessary information about the child's and family's strengths and needs. The CLTS FS sections can be completed in any order within the web-based application. This facilitates the use of the screen with a variety of existing application forms and assessment tools. The certified screener should use their clinical interview and assessment skills to gather the needed information to complete the CLTS FS. The screener will need to ask questions in a variety of ways and use collateral informants as necessary. Collateral informants include other family members, Birth to 3 Program or school staff, formal or informal caregivers, health care providers, and other agencies serving the child. The screener must always have a face-to-face contact with the child, even if other informants are used. Once the screener gathers all needed information, the CLTS FS is
completed using the web-based application. Entering information into the
CLTS FS is completed separately from the interaction with the family and
child. It is critical that the certified screener's responses are accurate
and verified from a variety of sources as necessary. The screener must
strive to use objective clinical judgment and this could be affected by
completing the screen with the family present. The CLTS FS is a tool for
certified screeners to ensure smooth and timely access for the child and
family to long-term supports. It does not replace strong clinical and
interaction skills to form a relationship with the child and family. 1.11 Screening LimitationsResearch shows that the following limitations occur in all functional assessments or screens:
[Back to Top] This section outlines guidelines to increase inter-rater reliability of the CLTS FS despite the limitations noted above. A. Apparently Inaccurate Reports Functional eligibility screens cannot be based solely upon child or family self-report; nor can they be merely screener's judgment. Both of these extremes allow for too much subjectivity. The goal of the CLTS FS functional eligibility process is to be as objective as possible. When screeners are objective, the result is high "inter-rater reliability"--meaning that other screeners would choose the same answer as another screener. Each screener must gather as much information, objective data, as possible, and then ask, "Given all this information, what would other screeners choose for an answer?" When meeting with a child and their family, asking questions, asking for demonstrations, and observing evidence carefully provides additional objective information. The screener can be curious, rather than critical, about the reasons people respond to the assessment process with differing responses. A screener is often addressing the emotions and needs of the child and family. Emotions and needs may affect an individual's perspective. A certified screener with experience working with children and families will apply this expertise to assure an accurate CLTS FS result. If further questions and observations don't indicate the best answer for the CLTS FS, consider any other information the screener may note in health or school records. In summary, screeners should follow this three-step process:
If still not clear, refer the question to State Clinical Staff. B. Different Descriptions from Different People Different people will describe a child's abilities, needs and problems very differently. This is expected due to varying perspectives among reporters, and because children often act differently in different settings or even with different people. Parents' perspectives and knowledge often are very different from that of a professional who sees the child only once a week. Children may in fact act very differently at school and at home. Adults' opinions, values, stresses, coping abilities and risk factors all affect how those adults describe a child's needs and behaviors. Cultural values and expectations can also create differences in how people perceive and describe a child. The screener will consider all available information, such as health or school records. Then ask, "Given all this information, what would other screeners choose for an answer?" If the differences are because a child's status differs, say, between school and home, then follow the instructions for "Abilities Fluctuate" below. During a screening, parent(s) may convey a wide variety of emotions and attitudes. The certified screener's role is to recognize and respond to those feelings and perceptions and to help describe a child's abilities as accurately and objectively as possible. The screener must be aware of the affects of stress, interpersonal relationships and family dynamics on a person's perception of a child's behaviors and needs. Professional opinions do not override parents. Rather a screener must address parents' views and engage with interest and questions that gently focus on objective information about the child. Here again is the three-step process to follow:
C. Abilities Fluctuate The CLTS FS is a functional eligibility tool; it is not a complete assessment of a child's current status. Screeners are able to add additional notes or complete a comprehensive assessment with the CLTS FS as a broad baseline of information. The screening tool addresses some specific areas of skill and development, which may make it more difficult to choose the most accurate answer on the CLTS FS. Responses to ADL/IADL, Mental health and behavioral questions have different frequency requirements. These requirements are described in the instructions for those sections. Remember that the screen is taken in total; even if some ADLs are not
checked, the child could be eligible through different sections of the
CLTS FS. 1.13 Reliability of Screen and ScreenersThe CLTS FS has been established as a reliable functional eligibility tool when used by certified screeners who follow established policies and procedures including verification of diagnosis, health related services, activities of daily living and instrumental activities of daily living. An objective rating of a child's function, cognition, behavior and symptoms can be difficult. This is in part due to changing needs and expectations as a result of development. This difficulty calls for extra vigilance to ensure the greatest possible accuracy in the CLTS FS. Screeners should adhere to the following guidelines:
1.14 Impending DischargeWhen screening a child who will be discharged within approximately one week from a skilled health care facility, for example a hospital, an Intermediate Care Facility for Mental Retardation (ICF-MR), a State Center for Developmental Disabilities or an Institute for Mental Disorders (IMD), complete the screen based on how the child is expected to function upon their return home. This looking ahead is a normal part of discharge planning. If, for example, oxygen and intravenous (IV) will be stopped before the child goes home in two days, do not mark "IV" under treatment on the HRS portion of the screen. If the family is learning to do a two-person pivot transfer to prepare to use at home, indicate that the child needs assistance with transfers on the ADL portion of the screen, even if now the hospital does one-person transfers with a mechanical lift. The screener will need to gather additional information from facility staff and the child's parent(s) to get the most accurate picture of the child's needs at home, after discharge. The screener must be able to envision the child at home. Therefore, the screener must have experience in community care for the target group being screened. The CLTS FS should be redone if the child's condition or situation changes from what was expected at the time the screen was completed. 1.15 Note Sections on the CLTS FSNote sections are available on every page of the CLTS FS. This space is provided for the screener to enhance or support the items they have checked (or did not check) on each page. Some screeners may use the note section to complete necessary requirements for individual programs (e.g., narrative assessment for Waivers). However, this is NOT the primary purpose of the note sections as they relate to the CLTS FS. The PRIMARY purpose or expectation is that notes will be made to strengthen and corroborate items checked on the screen. If notes are added to existing notes on a page, the most current notes should always be at the top of the list. If a screener does not agree with previous notes on a page, or those notes are no longer applicable for the child, notes from previous screens can be deleted. Notes are always saved on the original screen and can be found in the History Screens section. Notes are to be entered in the following format: Date (mm/dd/yy): notes…Screener initials / program affiliation For example: The following specific notes are expected on certain pages:DIAGNOSIS: Note any specific diagnosis the child may have that was found on the Diagnosis Cue Sheet. Examples:
MENTAL HEALTH: Note all details regarding any check marks for specific Symptoms (Violence, Suicidality, Psychosis, Anorexia/Bulimia). Examples:
BEHAVIOR: Note a detailed description of any check marks for specific Behaviors, especially those which occur at a frequency of "1-3 times/week" or "more than 4 times/week" and anytime "Other" is checked. Examples:
When another person (e.g., another screener, hearing officer, parent or CLTS FS Clinical Advisor) looks at a screen you have completed, it should be clear from reading the brief notes, why certain questionable items have been checked (or not checked) on the screen. This does not mean that there needs to be a note made every time a check mark is made. The critical notes are those that address items on the screen that might be questioned by someone else reviewing the screen. Examples of items not requiring notes:
Examples of items requiring notes:
1.16 Obtaining, Deleting or Changing Access for Certified ScreenersACCESS FOR NEW SCREENERS
RESTRICTING ACCESS TO SCREENERS WHEN THEY LEAVE OR TRANSFER EMPLOYMENT
MAINTAINING ACCESS WITH A CHANGE IN NAME OF AN EMPLOYEE
MAINTAINING ACCESS WITH A CHANGE OF EMAIL FOR AN EMPLOYEE
1.17 Resources for Certified ScreenersCLTS FS Listserv To join the Listserv, go to the Functional Screen Listserv website
at: To unsubscribe from the Listserv, go to the Functional Screen
Listserv website at: DHS Website for the Functional Screen
Clinical Advisor for the CLTS FS SOS Help Desk |