CLTS FS Instructions Module 1 - Overview of the Children's Long-Term Support Functional Screen

1.1 Introduction
1.2 Programs and Levels of Care on the CLTS FS
1.3 Protecting the Family’s Information and Rights
1.4 The Screening and Interview Process
1.5 Screening and Re-Screening Requirements
1.6 The NFE Process
1.7 Reliability of Screen and Screeners
1.8 Requirements for Screener Qualifications and Quality Assurance
1.9 Screening Considerations
1.10 Impending Discharge Back to Home

1.1 Introduction

The Wisconsin Children’s Long-Term Support Functional Screen (CLTS FS) is an eligibility tool that captures the needs of a child in a variety of developmental, behavioral, health, and daily living activities. It provides functional eligibility determinations for several programmatic areas, four functional levels of care (LOC) (explained below), and three target group designations 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 screener, and reference materials for certified screeners, see the Wisconsin’s Functional Screen webpage.

The CLTS FS is complex in that:

It appropriately adjusts questions for children as they develop from birth through young adulthood (until age 22).
It determines functional eligibility for multiple programs.
It determines multiple LoC and target groups.

Functions of the CLTS FS

In addition to providing a functional eligibility determination, the CLTS FS gathers and stores all information collected in the functional screen process. This data assists in quality assurance, national and state-level outcome measures, and provides information to counties and agencies as appropriate.

It is important to note the CLTS FS is not:

An assessment of the child or family. The functional screen is a deficit-based tool designed to capture the limitations of a child. An assessment is goal-oriented and focuses on the child progressing towards mutually developed goals based on strengths and needs.
A place to record financial, personal, or any other information not related to the child’s functional abilities.
A place for general case notes.
An evaluation of parenting skills.

The CLTS FS has been designed, operated, evaluated, and improved through a rigorous quality management system. The CLTS FS was designed by skilled clinicians from each of the programmatic areas, as well as others with child development experience. The initial success of the screen can be attributed to the willingness of program staff and county agency partners to test the screen extensively for validity and inter-rater reliability throughout its development. The testing demonstrates that the screen provides accurate functional eligibility results across multiple LOC and programmatic areas. Quality assurance processes have been established to prevent a child from being wrongfully denied functional eligibility. State staff continue to address screener questions, review questionable functional eligibility results, develop screen updates with clear written instructions, provide comprehensive training and support to new and certified screeners, and notify screeners of improvements to the screen to maintain a high level of validity and reliability.

Maintenance and improvement of the functional screen is an interactive process. Continuous improvement includes random reviews of individual screens for accuracy, documentation of screeners’ responses, analyses of individual screens and data (for example, comparing screen functional eligibility determinations to those of previous tools), and analyses of aggregate data to determine if screen results remain reliable. These efforts ensure that screen issues are identified and corrected in a timely manner.

The components of the CLTS FS are as follows:

Individual information: Screen identifying data, child's demographic information, residential setting, and legal concerns.
Contact information: Contact information for child's parents, guardians, and other significant individuals.
Diagnoses: Child's diagnostic information pertaining to a functional eligibility determination.
Mental health: Mental health status information regarding duration of condition, severe symptoms, needed services, and extreme circumstances.
Behaviors: Behavior categories include High Risk, Self-Injurious, Aggressive/Offensive, and Lack of Behavioral Controls and each relevant behavior’s frequency, duration, and interventions used.
Activities of daily living: Specific items to indicate need for support in bathing, grooming, dressing, eating, toileting, mobility, and transfers. Specific to age groups.
Instrumental activities of daily living: Specific items to indicate need for support in communication, learning, social competency, meal preparation, and money management. Specific to age groups.
School and work: School attendance and compliance, special education related data, support needed to transition to adult services, employment information, and preferences.
Health related services: Medical and skilled nursing information including terminal conditions, tracheostomy, ventilator, dialysis, IV, oxygen, respiratory treatments, TPN, tube feedings, therapies, colostomy, catheter, and wound or site care.

The CLTS FS provides the opportunity for certified screeners to describe the needs of children requiring long-term support to live at home, in substitute care settings, or in institutions. 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:

Objectivity and reliability: The CLTS FS is designed to be as objective as possible to achieve the highest inter-rater reliability (two screeners would answer the same way for a given child), to ensure fair and proper functional eligibility determinations, and provide statewide consistency.
Accuracy: Functional eligibility determinations must be correct and match the current Institutional Level of Care Guidelines.
Inclusive: Children of all ages and cultural backgrounds—with emotional, cognitive, physical, or developmental disabilities; with or without skilled nursing needs; in any setting from transient to institutions—can be accurately screened with the given choices for each developmental and activity subsection.
Clarity: Definitions and answer choices, including diagnoses and nursing needs, must be clear to screeners with a wide array of professional backgrounds.

1.2 Programs and Levels of Care on the CLTS FS

The CLTS FS determines functional eligibility for people from birth to age 22 years for several programs:

Children’s Community Options Program (CCOP)
Children’s Long-Term Support (CLTS) Program
Katie Beckett Medicaid
Comprehensive Community Services (CCS) Program
Community Recovery Services (CRS)
Mental Health Wraparound

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; it is a functional eligibility tool. Once the CLTS FS is complete, the computer functional eligibility logic will determine which, if any, of the four institutional levels of care (LOC) requirements are met.

The four institutional LOC are:

Hospital (HOS) = Physical Disability (PD) Target Group
Psychiatric Hospital = Mental Health Target Group
Nursing Home (NH) = Physical Disability (PD) Target Group
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) = Developmental Disability (DD) Target Group

An LOC is required for both the CLTS Program and Katie Beckett Medicaid. Additionally, the related target group(s)—physical disability, mental health, or developmental disability—for the CLTS Program is determined.

The CLTS FS also provides a functional eligibility determination for CCOP and CCS. Screeners must select at least one program for the screen to calculate, but the screen automatically calculates the child’s functional eligibility for all programs. Since the CLTS FS calculates eligibility for all programs, a screener is completing a screen for all programs every time. Functional eligibility results may show that a particular child meets functional eligibility for some programs, but not others. Some programs have other eligibility criteria that need to be met.

For children in the CLTS Program, county waiver agencies (CWAs) must begin planning for the child's transition to adult waiver services by the time the child is 17 years and 6 months old. When a youth reaches age 17 years and 6 months of age, the CWA must refer the CLTS participant and/or family to the local Aging and Disability Resource Center (ADRC) for options counseling.

The children and adult functional screens 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, long-term care programs will only accept the results from the most appropriate functional screen. If a person is 19 years old and using one of the children’s programs, then the CLTS FS should be used. Likewise, if a person is 19 years old but using one of the adult programs then the adult FS is to be used.

Social Security Disability Determination

A child must have a Social Security Administration (SSA) disability determination for Katie Beckett Medicaid. If the child has not had such a determination or their disability status is unknown, the screen will display “pending a disability determination” on the eligibility results page.

1.3 Protecting the Family’s Information and Rights

Guardian(s) may refuse to provide the necessary information or refuse to have a CLTS FS completed. This decision may result in the child not being able to access Medicaid and long-term support services.

Confidentiality

Screening agencies shall comply with state and federal confidentiality laws, including Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. The agency shall obtain a signed release of information from the child's parent(s) or guardian(s) for the use of medical, educational, and other records before conducting the CLTS FS. Copies of the signed releases of information shall be included in the child's records.

Any information collected during the screening process is confidential. Information shall be treated with the requirements for confidentiality within the current system of long-term supports.

Supportive Decision-Making

Wisconsin state law formally recognizes Supported Decision-Making agreements as legal arrangements that allow persons to retain their right to make their own decisions, while also choosing trusted people (called Supporters) to help them gather and understand information, compare options, and communicate their decisions to others.

More information for screeners and families can be found in the Supported Decision-Making Toolkit (PDF).

See Module 2.8 for more information regarding Supportive Decision Making.

1.4 The Screening and Interview Process

The screening process requires a meeting to complete the CLTS FS. Review specific program manuals for visit requirements.

The certified screener uses their interview 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 sources as necessary. Collateral sources may include other family members, Birth to 3 Program or school staff, formal or informal caregivers, health care providers, and other agencies providing services to the child.

1.5 Screening and Re-Screening Requirements

All programs using the CLTS FS require an initial screen to establish functional eligibility before receiving services. Screeners must verify that a screen was not completed in the past 12 months that already determined eligibility for a needed program. If a screen already exists and the child was found functionally eligible for that program, that screen must be used. If functional eligibility has not been determined for a given program, another screen can be completed. If a screen was completed within the last 12 months that shows functional eligibility but a screener does not have access to it, the screener must contact the owning screener/agency to request a transfer. Additional information regarding screen transfers can be found in Module 11.

If a screener tries to create a new initial or rescreen for a child that has had a screen completed and calculated within the last 12 months, a warning pop-up will appear. This will alert screeners to this screen and the need to check this previous screen for functional eligibility before continuing. If the screener wishes to continue, the warning message acknowledging the existence of a screen less than 12 months old must be selected.

An initial screen is chosen when:

A child has not been found eligible for a program using the FS in the previous 12 months.
A child was previously eligible and is seeking access again but there is over a one year gap between screens.

In both scenarios, if changes are made following an initial screen calculation within the first year of eligibility, screeners should edit that screen instead of beginning a new screen.

A rescreen, or recertification, is required annually from the month initial or previous eligibility was determined. This ensures continued eligibility for programs and continuity of services and supports. Rescreens are limited to once per year for all programs.

Rescreen is chosen when the child has been enrolled for a program within the previous year only.

1.6 The NFE Process

If upon initial or rescreen, a child is found not functionally eligible (NFE), screeners are required to have a peer in their organization review the screen for quality assurance. If the screen continues to be NFE screeners must contact DHS at dhscltsfs@dhs.wisconsin.gov to verify the NFE status.

When a screener conducts a functional screen for a child who is applying for waiver services and the screen finds the child to be NFE for the waiver program:

The screener will not check the box on the eligibility results page to transfer the results.
A second screener must review the screen.
If the screen continues to be NFE, contact DHS (email dhscltsfs@dhs.wisconsin.gov with “NFE Review” as the subject line) within 10 calendar days to confirm the NFE calculation.
If it is a rescreen, the screener will delay disenrolling the child from the waiver program until the NFE determination is confirmed by both the second screener and DHS.
If the NFE is confirmed, the screen completion agency will send the family a notice of denial, along with a description of the applicant’s state appeal, county grievance rights, and a copy of the functional screen with eligibility report according to programmatic notice timelines.

1.7 Reliability of Screen and Screeners

The CLTS FS has been established as a reliable functional eligibility tool when used by certified screeners who follow established policies and procedures. Because developmental functioning and expectations change as the child ages, it is important to ensure the greatest possible accuracy by verifying diagnoses, health-related services, activities of daily living (ADLs), and instrumental activities of daily living (IADLs).

Screeners must adhere to the following guidelines:

Screeners must closely follow screen definitions and instructions. Screeners are notified whenever updates are made to the screen and instructions and must adapt their use of the CLTS FS per these changes.
Screeners must ask every question on the screen to ensure accuracy utilizing their interviewing skills, even when they know a child well.
Screeners must select the answer that most accurately describes the child’s functioning. The functional eligibility logic is complex and uses information gathered from all sections of the CLTS FS. Screeners should use the tools available to them on the Wisconsin Functional Screen webpage (including the Diagnosis Cue Sheet, various Tip Sheets and Assessment Tools).
The screen logic compiles all responses and compares this to functional eligibility, level of care, and target group information. If a screener gets an unexpected result for any of these areas, the CLTS FS email (dhscltsfs@dhs.wisconsin.gov) must be contacted.
Screeners are expected to refer all questions and concerns to the CLTS FS email at dhscltsfs@dhs.wisconsin.gov.
If a screener receives a not functionally eligible (NFE) result, they must follow the NFE protocol described above in Section 1.6.

1.8 Requirements for Screener Qualifications and Quality Assurance

Special requirements for quality assurance and screener qualifications are necessary because the CLTS FS determines functional eligibility. The screener must have experience regarding the unique needs and functioning of children with significant disabilities. The screener must complete training to become a certified screener, along with ongoing reviews of their reliability.

Parallel to the qualification and certification requirements stated above, there are quality performance and assurance requirements to ensure consistency and accuracy of screen administration. There are three levels of CLTS FS quality assurance:

Individual Screener Quality Assurance Review. It is the screener's responsibility to be objective, informed of the instructions, and to verify information gathered regarding a child. The CLTS FS email box (DHSCLTSFS@dhs.wisconsin.gov) can address questions that arise as a screener completes a given child’s CLTS FS. Screeners should contact the CLTS FS email box whenever they obtain an unexpected result for a child. This includes eligible 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 given a child’s circumstances.
Agency-Level Quality Assurance Review. Agencies are responsible for the accuracy of all screens completed by their staff.
The methods each agency conducts will include:
- Participating in all required inter-rater reliability testing.
- Appropriate training, mentoring, and monitoring of new screeners.
- Reviewing a random sample of CLTS FS for accuracy on an ongoing, agency-wide basis.
- Review all available reports in FSIA.
- Following up on all quality assurance inquiries and providing documentation for all responses on the CLTS FS.
- Emailing the CLTS FS email box (DHSCLTSFS@dhs.wisconsin.gov) regarding any screen results or inaccuracies discovered.
State-Level Quality Assurance Review. DHS reviews screens and uses quality assurance methods during weekly, quarterly, and annual reviews. Screeners must make any suggested changes or provide a rationale for why the change cannot be made. If DHS staff disagrees with the rationale, the screener must follow the guidance issued by DHS.

1.9 Screening Considerations

Children will often improve with the added services and supports provided by long-term care programs. It is important to consider what their baseline of needs and behavior would be if those services and supports were not in place.

Different people will describe a child’s abilities, needs, and problems differently.
People often provide different information at different times or to different screeners.
People may observe different functional abilities and needs over time or across different settings (such as home or school).
Screen answers vary somewhat depending on whether the screener knows the child.
Screen answers vary somewhat depending on the environment in which the screener observes the child.

Strategies to Minimize Screening Limitations

This section outlines guidelines to increase inter-rater reliability of the CLTS FS despite the limitations noted above.

A. Determining a Child’s Needs on the Functional Screen

Most of the information needed to accurately complete a functional screen can be obtained from the child’s family or primary caretakers using interviewing techniques and by observing the child in their natural environment. When more information is needed to complete an accurate screen, others involved with the child’s daily life should be interviewed. If additional people continue to give an incomplete picture of the child’s needs, resulting in a not functionally eligible (NFE) result, recent testing or added documents can help complete the CLTS FS.

In summary, screeners should follow this process:

Ask more questions of the family or primary caretaker about what the child can do (for example, Ask the parents and child how they bathe (for example, in the bathtub, shower, or sponge bath). Ask to look at the child’s bathroom to check for accessibility and adaptive equipment. Ask both parties how they get in and out of the bathtub. If the bathtub has high sides, ask the child if they can lift their foot that high).
Rely on their (screeners’) professional expertise in interview skills and observation. Ask the family or child for additional details or a demonstration of a skill. Consider the whole picture.
Keep in mind that parents and caregivers can be giving assistance without realizing it. What has become baseline for a family may be considered functional support by the screen.
Seek additional information from other people, such as other family members, teachers, therapists, and physicians: those who interact with the child in a variety of settings. They may have opinions and objective information (for example, “They’ve fallen at least four times in the bathroom,” or “They are embarrassed to ask for or accept help in the bathroom even when they need it.”).
Review provided tools on the Wisconsin Functional Screen webpage.
If questions remain, contact DHS at dhscltsfs@dhs.wisconsin.gov.

Screeners should include detailed notes to explain selections when choosing the appropriate response is challenging or when they want to elaborate on their selection.

B. Different Descriptions from Different People

Different people describe a child’s abilities, needs, and problems very differently. This is expected due to varying perspectives and because children often act differently depending on the setting and people present. Parents’ or guardians’ perspectives and knowledge will be different from that of a professional who doesn’t see the child every day. Adults’ opinions, values, coping abilities, risk factors, and cultural expectations also affect how they perceive and describe a child.

The screener will consider and use all available information to complete the screen. Professional opinions do not override the family. Rather, a screener must address their views and engage with interest and questions that gently focus on objective information about the child. A screener should ask more questions and rely on professional observation. Consider the whole picture. Seek additional information from other people if needed, such as other family members, teachers, therapists, physicians, and other professionals.

C. Additional Notes

The CLTS FS is a functional eligibility tool, not an assessment. Screeners may add additional notes on the FS as long as the notes are objective and address the specific areas of skill and development relevant to functional eligibility criteria.

Responses to Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL), Mental Health, and Behavioral questions may require an entry about frequency of the activity or interventions used. 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.

1.10 Impending Discharge Back to Home

When screening a child who will be discharged from a skilled health care facility or hospital, an intermediate care facility for individuals with intellectual disabilities, a state center for developmental disabilities, or an institute for mental disorders, complete the screen based on how the child is expected to function upon their return home (for example, if oxygen and intravenous (IV) will be stopped before the child goes home in two days, do not mark “IV” on the health-related services (HRS) portion of the screen). If the family is learning to do a two-person pivot transfer to use at home, indicate that the child needs assistance with transfers on the ADL portion of the screen. The screener will need to gather additional information from facility staff and the child’s parent(s) or guardian(s) to get the most accurate picture of their needs after discharge.