LTCFS Instructions Module 1: Overview of the Long Term Care Functional Screen (LTCFS)
Glossary of Acronyms, P-01010 (PDF) | LTCFS Paper Form, F-00366 (PDF)
- 1.1 History
- 1.2 The LTCFS Determines Eligibility for Long-Term Care Programs
- 1.3 Other Functions of the LTCFS
- 1.4 Requirements for Screener Qualifications
- 1.5 Requirements for Quality Assurance
- 1.6 The LTCFS Is Voluntary
- 1.7 Confidentiality
- 1.8 Screening and Rescreening Requirements
- 1.9 The Screening Process
- 1.10 Reliability of Screen and Screeners
- 1.11 Screening Limitations and Strategies to Mitigate Limitations
By the end of this module, the screener should be able to:
- Explain the major criteria used to develop the LTCFS.
- Explain the purpose for the LTCFS.
- Explain how the LTCFS is to be administered, by whom, and in what manner.
- Utilize strategies for minimizing identified screen limitations.
- Document fluctuations in abilities and long-term care needs of people being screened.
- Recognize circumstances that require consultation with a medical professional to properly complete the health-related sections of the LTCFS.
The Wisconsin Adult LTCFS has been in use, in paper and electronic format, since 1997. The LTCFS describes the assistance a person needs with the following activities and conditions:
- Activities of Daily Living (ADLs)
- Instrumental Activities of Daily Living (IADLs)
- Additional Supports
- Health-Related Services (HRS)
- Communication and Cognition
- Behavioral Health
The LTCFS also includes information related to mental health and substance use and the person’s preferred living arrangement.
The LTCFS web-based application (Functional Screen Information Access, or FSIA) contains logic that interprets data to determine an adult’s nursing home level of care, intellectual/developmental disability level of care, and functional eligibility level for Wisconsin's long-term care (LTC) programs. The LTC eligibility and nursing home level of care logic has been tested for reliability and validity, and approved by the Centers for Medicare & Medicaid Services to replace previous methods of Medicaid home and community-based waiver services functional eligibility in Wisconsin. The major advantages of the LTCFS are that eligibility determinations are issued upon completion of the LTCFS and reflect an objective method of eligibility determination.
The LTCFS is different from other screening tools such as the Minimum Data Set (MDS) completed in nursing homes and Outcome and Assessment Information Set (OASIS) tool used by home health agencies because it must meet the needs of Wisconsin's LTC programs. In particular, the LTCFS works for all three federal Medicaid target groups: frail elders with health conditions or dementia (mild or severe); adults with physical disabilities (some with health conditions); and people with intellectual/developmental disabilities with various cognitive functioning levels, behavior symptoms, and/or health conditions. The LTCFS functions to capture the needs of people living at home as well as those in substitute care settings such as group homes and adult family homes, or institutions, including nursing homes and facilities serving people with developmental disabilities, also known as intermediate care facilities for individuals with intellectual disabilities (FDD/ICF-IID). Other criteria used to develop the LTCFS include the following:
- Clarity: Screeners from a variety of professional disciplines must clearly understand definitions and answer choices.
- Objectivity and Reliability: The LTCFS is as objective as possible to attain highest possible "inter-rater reliability," i.e., two screeners should answer the same question in the same way for a given person. Subjectivity is minimized to ensure fair and proper eligibility determinations.
- Brevity: The LTCFS determines program functional eligibility. It serves as a baseline of information about the person. A more in-depth assessment is needed to develop a service plan that reflects the person's strengths, values, and preferences for long-term care services.
- Inclusiveness: The LTCFS accurately describes each person within the responses available.
1.2 The LTCFS Determines Eligibility for Long-Term Care Programs
The LTCFS determines functional eligibility for long-term care programs for persons who are frail elders, have physical disabilities, dementia, a terminal illness, or intellectual/developmental disabilities. A person must be 18 years of age or older to participate in a publicly funded long-term care program for which the LTCFS determines eligibility. These programs are Family Care, Family Care Partnership, PACE (Program of All-Inclusive Care for the Elderly), and IRIS (Include, Respect, I Self-Direct). Early screening is available for persons aged 17 years 6 months or older to assist planning for transition to the adult long-term care system.
Once a screener completes an applicant's LTCFS, the eligibility logic built into the web-based application determines the person’s level of care and functional eligibility for Wisconsin’s adult long-term care programs. Wisconsin has the following four nursing home levels of care (for adults with physical disabilities and frail elders):
- Intermediate care facility, level 2 (ICF-2)—Lowest needs
- ICF level 1 (ICF-1)—Moderate needs
- Skilled nursing facility (SNF)—High needs
- Intensive skilled nursing services (ISN)—Highest needs
Wisconsin has four institutional levels of care for people with intellectual/developmental disabilities (I/DD):
- DD1A—People with significant medical problems in addition to cognitive disabilities
- DD1B—People with significant behavioral problems in addition to cognitive disabilities
- DD2—People who have a cognitive disability and are neither DD1A nor DD1B level of care and who need help with all or most ADLs and IADLs
- DD3—People who have a cognitive disability and who are more independent with most ADLs and IADLs
Level of Care in Medicaid Home and Community-Based Services Waiver Programs:
In general, Wisconsin's federally approved Medicaid home and community-based services long-term care programs require that the applicant achieve a qualifying nursing home (NH) or intellectual/developmental disability (I/DD) level of care on the LTCFS, as described above. People who do not meet a nursing home level of care may still be eligible for a more limited Family Care non-nursing home level of care benefit.
Level of care and functional eligibility criteria interact as eligibility is determined. For example, applicants who have shorter-term needs (more than 90 days, but less than one year) may still achieve a nursing home level of care and may be eligible for the Family Care program at a nursing home or non-nursing home level of care. However, these people will not be eligible for IRIS.
The remainder of this section describes NH and I/DD level of care (LOC) and how these interact with Family Care eligibility.
NH or DD Level of Care and Family Care:
To qualify for nursing home or DD level of care, a person must have a long-term care condition likely to last more than 90 days.
The NH and DD levels of care interact with the two levels of Family Care eligibility. The two levels of Family Care eligibility are "Family Care Nursing Home LOC" and "Family Care Non-Nursing Home LOC."
- Family Care Nursing Home LOC: Family Care nursing home LOC includes all three nursing home levels of care and all four DD levels of care. If a person receives a NH or IDD level of care, they are eligible at the Family Care nursing home LOC.
- Family Care Non-Nursing Home LOC: People at the Family Care non-nursing home LOC usually need help with only one or a few ADLs or IADLs and do not have a nursing home LOC or DD LOC. Only those people at the Family Care non-nursing home LOC who are financially eligible for Medicaid are entitled to the limited non-nursing home benefit package.
Screeners should confirm all health-related services with a nurse or other health care professional familiar with the person. When unsure about whether someone meets the level of care, screeners should consult with their agency’s screen liaison, who can contact the Department of Health Services (DHS), if necessary.
1.3 Other Functions of the LTCFS
- Serves as a foundation for the comprehensive assessment performed by the long-term care program selected by a person.
- Provides data for quality assurance and improvement studies for DHS and long-term care programs utilizing the LTCFS, including identifying cases for targeted reviews.
- Indicates the need for referrals to adult protective services, mental health services, substance use services, or other community resources.
- Provides actuarial information for rate setting and monthly allocations within some long-term care programs.
1.4 Requirements for Screener Qualifications
The LTCFS determines Medicaid waiver program functional eligibility. Therefore, screeners must meet specific qualifications that ensure knowledge of long-term care needs in order to ensure reliable screening and consistent LTCFS administration.
All people administering the LTCFS must meet the following four requirements:
- Meet the minimum criteria for education and experience, which are:
- Bachelor of Arts or Science degree, preferably in a health or human services related field or have a license to practice as a registered nurse in Wisconsin pursuant to Wis. Stat. §441.06, and at least one year of experience working with at least one of the target populations (frail elder, physical disability, or intellectual/developmental disability).
- Meet all training requirements as specified by DHS:
- Completion of the web-based clinical certification course. This course is currently the primary way to meet the DHS training requirements.
- Have at least one year of experience working in a professional capacity with long-term care consumers.
- Successfully complete all mandatory certification courses, exams, refresher courses, and continuing skills testing as required by DHS.
Each screening agency must identify a liaison to DHS in regard to screening activities performed by the agency. The duties and responsibilities of this person are defined in contracts between DHS and screening agencies.
1.5 Requirements for Quality Assurance
There are quality performance and assurance requirements in addition to the qualifications, training, and certification requirements for screeners in section 1.4. These promote the consistency and accuracy of administration of the screen by screening agencies. There are three components of functional screen quality assurance.
- LTCFS quality assurance efforts begin with each screener. It is the screener's responsibility to be an objective screener, to be informed of the instructions, and to corroborate information gathered from the person and collateral contacts. If a screener has questions, these should be addressed by the person designated as the screen liaison in each screening agency. The LTCFS results issue a determination of functional eligibility for Medicaid waiver programs. Therefore, screeners should be aware that unethical or fraudulent performance of screening activity will be referred to the DHS Office of the Inspector General for investigation.
- Part of the screen liaison's role is to oversee quality assurance activities related to the LTCFS. At a minimum, each agency must include the following strategies:
- Ensure completion of continued skills testing by all certified screeners.
- Train, mentor, and monitor both new and experienced screeners.
- Perform random sampling for accuracy and consistency of screens performed by each screener at the agency.
- Complete reports as required by DHS.
- Consult with the DHS LTCFS staff about complicated screens or to clarify policy and procedure.
- Discontinue access to FSIA for any screener whose job duties or employment status has changed.
- Respond to quality assurance findings of DHS.
For additional guidance on the role of the Screen Liaison, refer to the Screen Liaison Toolkit document, Role of the Screen Liaison, P-02783. (PDF)
- DHS performs continuous monitoring of screener performance, screen accuracy and completeness, and appropriate use of the web-based screen application by staff at all screening agencies. Screening agencies will be required to perform corrective action to improve or remediate DHS findings.
1.6 The LTCFS is Voluntary
Individuals, or their legal guardians, must consent to having the LTCFS completed in order to enroll in a long-term care program (IRIS, Family Care, Family Care Partnership, or PACE). The LTCFS should not be completed without the consent of the person being screened or their legal guardian.
Screening agencies must comply with confidentiality rules and requirements and must obtain a signed release of information from the person being screened, or their legal guardian, where applicable, to collect medical records, educational records, and other records needed to complete the screening process. Signed releases of information must be retained in the person’s case record.
All information collected for the LTCFS or during the screening process is confidential. It is to be treated following the same requirements for confidentiality as other long-standing screens and assessments that contain personally identifying health information.
When an aging and disability resource center (ADRC) or tribal aging and disability resource specialist (ADRS) refers a person for enrollment in a long-term care program, the person’s functional screen may be shared with that program without separate written authorization. Long-term care programs do not need written permission to refer people to an ADRC. Each ADRC has access to view the functional screen in FSIA for any person served by a long-term care program that operates within the coverage area of the ADRC. When an individual transfers between long-term care programs or agencies, refer to DHS guidelines regarding disenrollment or transfer. An individual’s LTCFS information can be transferred to the new agency without the individual‘s informed consent under Wis. Stat. § 46.284(7).
Release of a functional screen to another person or any other entity requires written authorization by the person screened, or their legal guardian when appropriate.
1.8 Screening and Rescreening Requirements
Initial screening and annual screening:
An initial LTCFS is required in order to establish level of care and functional eligibility for all publicly funded long-term care programs serving adults in Wisconsin. An annual screen is required thereafter to determine continued level of care functional eligibility.
ADRCs and tribal ADRS provide counseling to potential long-term care consumers and their families about all long-term care options, regardless of whether the individual needs public assistance to pay for services or can pay privately. The ADRC or tribal ADRS is the initial screen agency for people seeking publicly funded long-term supports.
ADRCs and tribal ADRS provide information and assistance, early intervention and prevention, and urgent services and inform the public about community resources within the LTC system and the community. The multifaceted nature of ADRCs and tribal ADRS helps individuals get information on all long-term care eligibility and options.
The LTCFS is also administered by long-term care program staff at managed care organizations (MCOs) and IRIS consultant agencies as part of their program activity and for annual functional eligibility determinations. However, long-term care programs may not be involved with performing the LTCFS or performing prescreening for a person prior to that person’s enrollment in the long-term care program.
Change of condition screening:
If a person enrolled in a LTC program experiences a substantial change of condition, then the person must be rescreened to determine if the change in condition impacts the person’s level of care.
The following are examples of changes of condition when rescreening is necessary:
- Larry, an 88-year-old program participant, has a stroke.
- Mary, a 79-year-old woman, regains her mobility after recovering from a hip fracture.
- Jose, a 44-year-old man with Down syndrome, is diagnosed with early onset dementia.
When rescreening, it is important that the screener review the person's previous screens for information and historical perspective. Functional eligibility may be calculated more often than annually if a person experiences a change in condition or requests to be rescreened.
The screener must document the nature of a change in condition in the Notes sections on the web-based LTCFS. Thorough notes:
- Assist the screening agency and DHS in assessing the completeness and accuracy of screens.
- Reduce the number of requests for information DHS makes during screen reviews.
- Assist the screening agency, DHS, and the Division of Hearings and Appeals in understanding the actions taken by a screening agency if an administrative hearing appeal is filed.
Screening during acute episodes:
Acute episodes refer to diseases or conditions of a short duration compared to a chronic disease or condition that persists over time. Typically, an acute episode is measured in days and weeks, whereas a chronic condition is measured in months and years.
Acute episodes may occur at home or in a hospital, nursing home, or other location. If a person experiences an acute episode at his or her current residence that results in a substantial change of condition, a rescreen may be done to determine if the change of condition impacts the person’s level of care.
It is expected that some LTCFS responses during the rescreening may reflect higher needs due to the acute episode or condition and that a person’s condition may improve over the days, weeks, or months following the acute episode.
When the person’s condition improves or is resolved, a rescreen must be completed.
If a rescreen is completed for a person who has been admitted to a hospital or other institution, the rescreen is done when preparing for discharge.
Screeners performing a LTCFS for a person who is preparing for discharge from a facility, such as a hospital, skilled health care facility, or IMD, must complete the LTCFS based on the person’s capacity for self-care and the supports and services the person is expected to need when he or she returns home. The discharge planning process anticipates a person’s functioning when he or she returns home in order to determine the supports and services the person will require.
For example, if a person were using oxygen and intravenous (IV) medication in a nursing home but was expected to stop these treatments before returning home, the screener would not make selections for these treatments on the HRS Table of the LTCFS. As another example, if a person were using a mechanical lift in a hospital but family members were learning to perform a two-person pivot transfer for use in the home, then the screener would not select equipment for lifting on the LTCFS. The screener would review the discharge plan and talk with facility staff, family, and others to get the most accurate picture of the person's needs at home, after discharge.
The screener must be able to envision the person at home based on the screener’s experience in community care.
1.9 The Screening Process
The screening process requires face-to-face contact with the person being screened. The LTCFS—initial, annual, or rescreen—must be completed based upon a meeting with the person, even if the person is unable to communicate.
The Interview Process
The LTCFS tool captures relevant information. It is not an interview tool. Screeners are expected to use professional skills to interview the person and assess the situation. Completion of the modules of the web-based LTCFS may occur in any order. It may take more than one contact with the person to complete the screen. The face-to-face interview may take place in any setting that is familiar to the person being screened, including, but not limited to, the person’s residence, a substitute care setting such as a community-based residential facility (CBRF), or at a hospital or nursing home. However, best practice is to perform the interview with the person and their family or collateral contacts in the person’s residence. This allows for discussion in a private setting and also allows the screener to observe the person in their natural environment.
Screeners should use their professional interview skills to gather information in a way that is appropriate for a given person. The screener will need to ask questions in a variety of ways, use communication strategies that best meet the needs of the person being interviewed, and use collateral contacts for additional information, as necessary. Collateral contacts include family, significant others, formal or informal caregivers, health care providers, and agencies serving the person.
The screening interview requires the screener to ask probing questions of a very personal nature. The screener must use tact and sensitivity to obtain honest and complete responses. Often, use of open-ended questions will result in the discovery of information that very specific questions will not uncover. Screeners must often look for visual clues, facial expressions, and interactions between the person and their significant others that may indicate undisclosed needs. A tour of the person’s home and direct observation of the person as they perform everyday activities is helpful, especially when there appears to be a discrepancy between the person’s report and the activities they perform.
When using translators or interpreters during a screening interview, ensure they understand that a Medicaid functional eligibility determination is being made and that they must not have a personal interest in the outcome of the determination. When relying on the person, family, friends, or caregivers to provide information during a screen interview, make them aware of the nature of the screen and inform them that coaching of responses or other activities that may result in an inaccurate portrayal of the needs of the person being screened, are not allowed. Refer instances of alleged Medicaid fraud to the DHS Office of the Inspector General at 877-865-3432.
1.10 Reliability of Screen and Screeners
The LTCFS has statistically acceptable levels of validity and reliability. However, it is generally recognized that any objective rating of the functioning, cognition, behavior, and symptoms of unique people can be difficult. This difficulty calls for a high level of vigilance by screeners to ensure the greatest possible accuracy in the LTCFS.
Screeners must adhere to the following guidelines:
- Read and follow screen definitions and instructions closely. The LTCFS Instructions document is reviewed and revised on a regular basis to improve the clarity of instructions and reflect the findings of the DHS quality monitoring activities.
- Make screen selections thoughtfully and carefully to ensure accuracy.
- Select the answer that most accurately describes the person’s needs. This response must not be influenced by factors such as cost of care that are not factors in determining the person’s level of care.
Recognize unexpected outcomes and follow the correct procedures to ensure the screen is complete and accurate.
Unexpected outcomes are target group and level of care results that do not appear to the screener to be congruent with the needs of the person being screened. The results may be different from prior screens, but if that change appears appropriate, then the results are not unexpected.
Whenever the results of a functional screen are unexpected by the screener, the screen is not considered complete and accurate. If the screen outcome results in an individual’s ineligibility to enroll in a program or may result in a potential disenrollment of the individual from a long-term care program, the results are not complete until the screener agrees that the results are appropriate based on a complete and accurate screen.
The screener should ask the screen liaison in his or her agency to review the screen. If, after that review, the results continue to be unexpected, the agency screen liaison should contact a functional screen quality specialist at DHS who will perform a full review of the screen and consult with the screen liaison until the screen results are considered complete and accurate. Once the screen is considered complete and accurate, the screener takes the action the screening agency requires based on the results of the screen.
Note: When a screener believes the screen results accurately reflect the individual’s needs, the screener does not need to request a follow-up review, even if the results have changed from the previous screen.
Refer all questions to your designated screen liaison. The screen liaison will refer unresolved questions to DHS. This process assures that interpretations are consistent and communicated to all agencies utilizing the LTCFS. Revisions will be made to the LTCFS, as deemed necessary by DHS.
1.11 Screening Limitations and Strategies to Mitigate Limitations
The following limitations have been identified in national studies to be characteristic of screening tools similar to the LTCFS:
- Health care and institutional providers tend to overrate the person's dependency on others.
- Guardians, spouses, and family members often tend to overrate the person’s dependency on others.
- People often underrate their need for help from others and tend to overrate their abilities.
- People’s functional abilities may fluctuate, making it difficult to select a "best" answer.
- People may provide conflicting information at different times or to different screeners.
- Screen selections may vary depending on the screener’s experience with the person.
- Screen selections may vary depending on the profession of the screener.
- Some subjectivity may remain even with questions and processes designed to promote objectivity.
The following sections guide LTCFS screeners on strategies to mitigate these potential limitations.
Conflicting Information from Different People
Screeners may get different information about people being screened from different sources. People may function less independently in day care facilities or institutional settings than they do at home. Staff at such facilities may tend to perceive more dependency than family or peers in the community perceive. Screeners must use professional judgment to describe the person's functional abilities as accurately as possible using the information from multiple sources. A good source of information, in addition to the person, is someone who does a lot of direct care for the person and with whom the person has a positive relationship. In a health care facility, the screener should talk to a nurse's aide in addition to the nurses. In the home, a personal care worker might provide a more accurate description than family members.
Person Gives Apparently Inaccurate Information
The statements made by a person about their abilities may not be consistent with needs and activity that are directly observed by the screener or those reported by others. If this occurs, then the screener will follow this four-step process:
- Seek more details from the person being screened.
- Seek additional information from collateral contacts.
- If possible, ask the person to demonstrate tasks such as getting into and out of the bathtub.
- Use professional judgment to make the most accurate selections while following the definitions and instructions for the LTCFS.
The goal is for the LTCFS screener to be as objective as possible, and to have high "inter-rater reliability"—meaning that other screeners would make the same selection on the person’s LTCFS. For this reason, the screener’s selections on the LTCFS must be based on as much objective information as possible. Objective information can be obtained by asking questions, asking for demonstrations, and observing evidence carefully. If selecting the appropriate response is still challenging, then discuss the concerns with the agency screen liaison, who can assist in marking the screen appropriately or request guidance from DHS. The screener should include detailed notes to explain the selections made on the LTCFS in these circumstances. For example, if a person who can barely walk and transfer himself tells you he bathes himself, but his poor hygiene indicates otherwise, then the screener would follow these steps:
- Seek more details: Ask him how he bathes (for example, in the bathtub, the shower, or a sponge bath). Ask to look at his bathroom to check for accessibility and adaptive equipment. Ask him how he gets in and out of his bathtub. If it has high sides, then ask him if he can lift his foot that high, and to show you.
- Seek information from collateral contacts: Ask him if you can talk with his family members. They may have opinions ("He should be in a nursing home") as well as objective information ("He's really gone downhill since mom died last year, he's fallen at least four times, he can barely move, he hasn't been in that bathtub for months, he won't accept any help from us even when we tell him he needs a bath.").
- Use your professional judgment to select the best answer: In this example, it seems he's definitely not independent with bathing. It's not exactly clear whether Bathing Level of Help #1 (helper does not have to be present throughout task) or # 2 (helper does have to be present throughout task) is most accurate. With the history of recent falls and his excessive independence, #2 might more accurately reflect what he really needs at this time.
Some screens or data collection instruments such as the MDS, required of nursing homes, and the OASIS, required of home health agencies, are designed to provide a "snapshot" view of a person’s functional status. These tools assess functioning in the past seven days or over the past month. The LTCFS allows for a broader timeline in order to more accurately reflect a person’s long-term care needs. Many long-term care participants have conditions and abilities that fluctuate over time. The screener will make the best selections possible on the LTCFS when addressing fluctuating needs. When completing the screen, use the following guidelines:
- If the person's functional abilities vary over months or years, then make selections that are closest to the average frequency of help needed.
- If the person's functional abilities vary day-to-day, then make selections that most accurately describe his/her needs on a "bad" day.
- If the person's functional abilities vary week-to-week, make selections that reflect the staff needed to meet the person’s need for assistance to maintain the person’s health and safety.