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LTCFS Instructions Module 6: Additional Supports

Glossary of Acronyms, P-01010 (PDF) | LTCFS Paper Form, F-00366 (PDF)

Contents

6.1 Introduction

This section describes additional supports that may be received by individuals who are being screened for eligible LTC services.

6.2 Selecting Primary and Secondary Diagnoses

To be selected as a primary or secondary diagnosis that causes a need for assistance or support from another person, the need must be due to a physical, cognitive, or memory loss impairment. Additional guidance can be found in Module 4.4 Identifying Primary and Secondary Diagnoses

6.3 Overnight Care or Overnight Supervision

To select a need for “Overnight Care or Overnight Supervision,” the individual must have a physical, cognitive, or memory loss impairment limiting their ability to independently complete overnight care tasks or that require overnight care or overnight supervision.

Overnight care is defined as the need for hands-on assistance or verbal cuing from another person, to complete an ADL or health-related services task, during the overnight hours.

Overnight supervision is defined as the need for someone to be present to prevent, oversee, manage, direct, or respond to a person’s disruptive, risky, or harmful behaviors, during the overnight hours. Overnight supervision is indicated for a person unable to respond appropriately in an emergency (for example, a vulnerable adult).

Overnight supervision is not indicated for a person without a physical, cognitive, or memory loss impairment who is uneasy being alone at night.

A person currently residing in a FDD/ICF-IID, nursing home, or residential care facility DOES NOT necessarily require overnight care or overnight supervision. You should ask yourself, "Would this person require overnight care or overnight supervision were the person not residing in an institutional or residential care facility?" Ask the facility’s staff whether the person being screened has ever demonstrated a need for assistance during the night shift. Does the person need to use the call button for staff at night? Or rather, does the person independently get to and from the bathroom at night?

REMINDER: Although licensed facilities have policies that require staff to monitor the residents at night, overnight care or overnight supervision is not necessarily needed by each resident.

OVERNIGHT CARE or OVERNIGHT SUPERVISION RATING SYSTEM

  0: No
  1: Yes; caregiver can get at least 6 hours of uninterrupted sleep per night
  2: Yes; caregiver cannot get at least 6 hours of uninterrupted sleep per night

Check this for a person who:

  • Needs help overnight from another person due to a physical or cognitive limitation jeopardizing their health and safety during that time.
  • Has a physical limitation that may require overnight care or supervision. To reflect a person’s NEED for assistance, the screener should select the most accurate answer that most closely describes the person's NEED for “help from another person,” whether the person is actually receiving that assistance or not. Help from another person is defined as supervision, cueing, and/or hands-on assistance (partial or complete).
    • If a person has an identified need but is not receiving assistance (this includes declining the assistance and a significant, negative outcome occurs), the screener should still capture the need for the assistance from another person to complete the task.
    • If a person has an identified need but they have declined assistance and there is no significant negative health outcome, the screener is to select Independent.
    • If a person has a legal guardian, an activated power of attorney for health care, or is currently involved with adult protective services, that person may be considered not able to perceive and recognize potential risks or negative health outcomes and the selection of a need might be appropriate.
  • Has limited cognitive abilities and needs overnight supervision, although the person does not need overnight care.
  • Has disruptive or risky nighttime behavior that requires intervention.
  • Has an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months that requires supervision and/or care.
  • Lives independently without assistance during the daytime but requires intervention or supervision during the nighttime due to an unstable mental health condition (such as posttraumatic stress disorder).
  • Can safely get through a day without needing a cue or reminder, is able to make safe routine decisions, but does not have the cognitive capacity to know when to call for help and requires assistance in an emergency such as a flood, fire, or tornado.
  • Has a remote monitoring system with an onsite or offsite response person, and in the last six months the system’s intervention was initiated in response to a need at least once.
  • Has a need for a room-to-room monitor, bed alarm, or door alarm system with an onsite or offsite response person.
  • Has a Personal Emergency Response System (PERS) and uses it during the nighttime hours to summon assistance with a physical care need.

Do NOT check this for a person who:

  • Does not have a physical or cognitive limitation jeopardizing their health and safety overnight.
  • Desires overnight care or overnight supervision based solely on an age, gender, or cultural norm.
  • Receives overnight care or overnight supervision but does not have an identified physical or cognitive limitation requiring that care or supervision. For example, a family member is uncomfortable with the person being alone at night, the person’s roommate requires overnight care or overnight supervision, or the person is up during the nighttime hours without a need for care or supervision.
  • Has a PERS and only uses it as a means of accessing assistance in the event of an emergency. The presence of a PERS alone does not by itself indicate a need for overnight care or overnight supervision.
  • Has a seizure disorder with no seizures in the last three months and there is no intervention needed; however, another person is present “just in case.”
  • Has a cognitive impairment without a physical limitation and can safely get through a day without needing a cue or reminder. Additionally, the person can make safe routine decisions and has the cognitive capacity to know when to call for help, and only requires assistance in an emergency such as a flood, fire, or tornado.
  • Has a cognitive impairment and a safety plan that they can articulate, which indicates they know how to respond appropriately in the event of an emergency.
  • Has a specific diagnosis. A need for overnight care or overnight supervision is not based solely on the person’s diagnosis.
  • Lives in a residential care setting, FDD/ICF-IID, or nursing home where overnight care or overnight supervision are provided based on facility policy and the person does not have an assessed need for those services.
  • Lives in a residential care setting with “sleep staff,” which refers to staff able to get at least six hours of uninterrupted sleep per night, although the person does not need overnight care or overnight supervision.
  • Lives in a residential care setting with “awake staff,” which refers to staff unable to get at least six hours of uninterrupted sleep per night, although the person does not need overnight care or overnight supervision.
  • For a person with a cognitive impairment, has a monitoring system with an onsite or offsite response person, and in the last six months the system’s intervention was NOT initiated.
  • Needs monitoring overnight related to their use of the internet.

6.4 Employment

This section concerns the need for assistance to perform employment-specific activities (job duties). Since a person’s need for help with ADLs and IADLs (for example, transportation or personal care) is captured in other sections of the LTCFS, this section specifically captures supports necessary for successful performance of work tasks.

Screeners should clearly inform the person being screened that responses to the employment questions will not detract from the person’s eligibility for Social Security, Medicaid, LTC programs, or other benefits.

The employment questions help to capture if individuals participating in LTC services are working and, if not working, if they are interested or may be interested in employment. These questions are asking for the person’s preference. The employment questions should not consider anyone else’s preference for whether the individual should work, where anyone else wants the individual to work, nor whether the screener or anyone else thinks it is realistic for the individual to work.

For an individual who is employed, the screener is asked to select the setting or settings where the person works. If the person is working in a facility-based setting, the screener must ask if the person is interested in working in the community. It is common that people will respond consistent with what they have experienced, been exposed to, or been told is an option. For example, people with intellectual/developmental disabilities who work in facility-based settings often think this type of work is the only option available to them. In this example, the screener should take the time to ask if the facility-based setting is their preference or if they have an interest in working in the community. When making a selection for an employment setting, screeners should ask questions to help the person articulate their preferences. While the person's preference may be difficult to ascertain, screeners are to use their best professional judgment to select the most accurate answer.

EMPLOYMENT RATING SYSTEM

A. Current Employment Status:

  1: Retired (does not include people under 65 who stopped working for health or disability reasons)
  2: Not working (No paid work)
  3: Working full-time (Paid work averaging 30 or more hours per week)
  4: Working part-time (Paid work averaging fewer than 30 hours per week)

B. If Paid Work, Where? (Check all that apply):

  1: Facility-Based Setting
  2: Group-Supported employment in the community (two or more) or individual employment in the community, with or without employment services, paid at subminimum wage
  3: Individual employment in the community, with or without employment services, paid at a competitive wage (minimum wage or higher)
  4: At home or self-employed

C. Need for Assistance to Work (mandatory for ages 18-64; otherwise optional):

  0: Independent (with assistive devices if uses them)
  1: Needs help weekly or less (for example, if a problem arises)
  2: Needs help every day, but does not need the continuous presence of another person
  3: Needs the continuous presence of another person
  4: Not applicable (please explain)

A. Current Employment Status
Choose one option that best describes the individual's status:

1: Retired (does not include people under 65 who stopped working for health or disability reasons)

Check this for a person who:

  • Is age 65 or older and is not in the workforce (whether receiving retirement benefits or not).
  • Is under age 65, receiving retirement benefits, and did not stop working because of a health problem or a disability.

Do NOT check this for a person who:

  • Stopped working before age 65 due to a health problem or a disability, even if the person describes it as an “early retirement.” Instead, check “2: Not working (No paid work).”
  • Is involved in unpaid pre-vocational activities only. Instead, check “2: Not working (No paid work).” This may include volunteer activities.

2: Not working (No paid work)

Check this for a person who:

  • Is under age 65 and is not working for pay for any reason (unless retired).
  • Is under age 65 and stopped working due to a health problem or a disability.
  • Is involved in unpaid pre-vocational activities.
  • Is involved in volunteer activities, including volunteer and in-kind work to meet Medicaid Purchase Plan (MAPP) eligibility requirements.

Do NOT check this for a person who:

  • Is age 65 or older and is not in the workforce. Instead, check “1: Retired (Does not include people under 65 who stopped working for health or disability reasons).”

If the response to A. Current Employment Status = 2: Not working (No Paid Work), and the person is between the ages of 18 and 64, the following question must be answered: Is the individual interested in employment? The answer to this question will be either “Yes” or “No.”

  • Select “Yes” if the individual indicates that they are interested in paid employment options.
  • Select “Yes” if the individual indicates that they may be interested in paid employment options.
  • Select “No” if the individual is not interested in paid employment options.
  • Select “No” if the individual is only interested in unpaid, pre-vocational, or volunteer activities.
  • Select “No” if the individual refuses or is unable to answer the question based on their preference.

3: Working full time (Paid work averaging 30 or more hours per week)

Check this for a person who:

  • Is earning income for working, on average, 30 hours per week or more.
  • Is earning income at facility-based employment, on average, 30 hours per week or more. This includes pre-vocational activities if paid, on average, 30 hours per week or more.
  • Is earning income through group-supported employment in the community that includes two or more workers if paid, on average, 30 hours per week or more.

Do NOT check this for a person who:

  • On average, is paid for fewer than 30 hours per week. Instead, check “4: Working part-time (paid work averaging fewer than 30 hours per week).”
  • Attends a facility-based pre-vocational program (for example, sheltered workshop), but is not participating in paid work for 30 hours per week or more.

4: Working part-time (Paid work averaging fewer than 30 hours per week)

Check this for a person who:

  • Is earning income for working, on average, fewer than 30 hours per week.
  • Is earning income at facility-based employment, on average, fewer than 30 hours per week. This includes pre-vocational work if paid, on average, fewer than 30 hours per week.
  • Is working at facility-based employment and is paid by piece-rate, not hourly, and on average, is paid fewer than 30 hours per week.
  • Is earning income through group-supported employment that includes two or more workers and is paid, on average, fewer than 30 hours per week.

Do NOT check this for a person who:

  • Is not working for pay.
  • On average, is paid for 30 or more hours per week of work. Instead, check “3: Working full time (Paid work averages 30 or more hours per week).”

Note: In pre-vocational service settings, wages are often paid by piece-rate rather than hourly. The screener only needs to determine if the time involved working for pay is fewer than 30 hours per week. This is most common. Typical full-time pre-vocational service program attendance is 30 hours per week; not all hours are typically paid, so paid hours are usually fewer than 30 hours per week.

B. If Paid Work, Where? (Check all that apply):
Skip this section if in Section A, “1: Retired” or “2: Not Working” was selected.

Check all that apply, as some individuals work in more than one type of employment location:

1: Facility-Based Setting
A facility-based setting is a sheltered workshop, also known as a community rehabilitation program, work center, or facility-based employment. They are distinguishable from mainstream employers by the fact that the primary mission of the corporation or entity is to provide services to individuals with disabilities, and they typically employ a large number of individuals with disabilities in one or more facilities. Facility-based settings may be licensed to pay sub-minimum wages to a group of workers with disabilities. Many facility-based settings provide other rehabilitation and long-term support services besides facility-based employment, which may include individual and small group supported employment, day services, therapies, and transportation.

If the response to B. If Paid Work, Where? = 1: Facility-based setting, the following question must be answered: Is the individual interested in working in the community? The answer to this question will either be “Yes” or “No.”

  • Select “Yes” if the individual indicates they are interested in employment in the community.
  • Select “Yes” if the individual indicates they may be interested in employment in the community.
  • Select “No” if the individual is not interested in employment in the community.
  • Select “No” if the individual is only interested in unpaid, prevocational, or volunteer activities, or if they prefer to work in a facility-based setting.
  • Select “No” if the individual refuses or is unable to answer the question based on their preference.

2: Group-supported employment in the community (two or more) OR individual employment in the community, with or without employment services, paid at subminimum wage
Group-supported employment is employment in a regular business, industry, or community setting where two or more workers with disabilities are employed as a group. Examples include mobile crews and other business-based work groups employing groups of workers with disabilities in the community. The worker may be compensated in accordance with applicable state and federal wage laws and regulations (for example, subminimum, minimum, or above minimum wage).

Work crews and enclaves are examples of group employment arrangements where two or more individuals with disabilities work in a team to perform work. The employer of record is typically the support provider agency (for example, sheltered workshop, community rehabilitation facility, work center). Because people with disabilities are grouped together, this is considered segregated employment, not community-integrated employment, even when the work crew or enclave does its work in a community setting.

Individual employment in the community, with or without employment services, paid at subminimum wage, is work compensated at less than the applicable state or local minimum wage (customary wage). The work should be at a location typically found in the community, where the employee with a disability interacts with people who do not have disabilities. Individual employment in the community may be performed by the person with a disability with or without employment support.

3: Individual employment in the community, with or without employment services, paid at a competitive wage (minimum wage or higher)
Individual employment in the community, with or without employment services, paid at a competitive wage (minimum wage or higher) is also known as competitive integrated employment (CIE). This is defined as work performed on a full-time or part-time basis and compensated not less than the applicable state or local minimum wage law (customary wage). The worker should be eligible for the level of benefits provided to other employees. The work should be at a location typically found in the community, where the employee with a disability interacts with people who do not have disabilities and are not in a supervisory role, and the job presents opportunities for advancement. Individual employment in the community may be performed by the person with a disability with or without employment support.

4: At home or self-employed
At home employment or self-employment is defined as work performed on a full-time or part-time basis that yields income comparable to a person without disabilities doing similar tasks. The work is located in the worker’s home or in an integrated work setting in the general workforce. Operating a microenterprise may be considered self-employment. Microenterprise is defined as a business operating on a very small scale, generally with a sole proprietor and fewer than 10 employees.

C. Need for Assistance to Work
A selection is mandatory for people aged 18-64, even if the person is not currently working.

A selection is not required and can be left blank for people who are:

  • Under age 18. 
  • Retired AND over age 64.

Choose one option that best describes the individual’s current or anticipated need

  0: Independent (with assistive devices if uses them)
  1: Needs help weekly or less (for example, if a problem arises)
  2: Needs help every day but does not need the continuous presence of another person
  3: Needs the continuous presence of another person
  4: Not applicable (please explain)

Predicting the need for assistance to work for those not currently working
If the person is not currently working, the screener will need to estimate the level of help, beyond reasonable accommodations, the person would likely need to work. This might be deduced from the person’s overall functioning and abilities. The screener should consider other information captured on the functional screen. The presence of a particular type of disability or health disorder (e.g., cognitive disability, seizures, chronic pain) or a guardianship does not automatically mean an individual will need the assistance of another person for successful performance of work tasks.

To decide which of the answer choices best represents the level of help needed to work, the screener should also consider the following:

  • If the person worked before and their ability to perform work tasks is unchanged, indicate the level of job help needed in the past.
  • Think about other factors not captured elsewhere on the LTCFS that create the need for employment supports. Examples include learning disorders, mental health or behavioral challenges, language barrier, or the need for job training or supervision not related to LTC needs. The existence of any of these does not automatically mean a person would need employment supports.

4: Not applicable

  • Should only be selected if the person aged 18-64 is severely ill or in a semi-comatose state. Severe disabilities themselves do not render a person unable to work. For a person with marked cognitive and/or physical disabilities, the screener should consider whether selection of 1, 2, or 3 is the most accurate choice.
  • Should not be selected simply because the person is retired or not interested in seeking employment. Even if the person is not expected to seek employment in the near future, the screener should estimate the level of assistance that would be needed if the person did begin work.
  • Explain in the Notes section why it is unreasonable to consider employment for this 18–64-year-old person, even with continuous assistance from another person.

6.5 Educational Information

Included in this section of the LTCFS are two questions that require a response of either Yes or No.

Question 1. Is the individual currently participating in an educational program?

Question 2. Does the individual need assistance from another person to participate in an educational program?

Participation in an educational program is defined as current and active enrollment in a class, and needing help from another person, above and beyond reasonable accommodations such as those listed below.

Educational programs include, but are not limited to, high school, technical school, and college with the intent to receive or maintain a degree, certification, or licensure. This also includes special education classes, educational programs requiring an IEP (Individualized Educational Program), or classes and courses where an individual requires consistent one-to-one assistance or an aide.

Educational programs do not include extracurricular or enrichment programs that are not part of a formal program as described above. Examples include, but are not limited to, recreational sports, arts and crafts, or introduction to a foreign language.

To capture the need for assistance to participate in an educational program, the individual must have one of the following:

  • Significant medical needs
  • Behavioral needs
  • Intellectual or cognitive impairments

Reasonable accommodations include, but are not limited to:

  • Transportation to and from the educational site.
  • Assistive devices and technologies.
  • Service animals.
  • Alternative format materials, such as Braille.
  • Limited English proficiency interpretation.
  • Simple, reasonable adaptations, such as taking one class at a time, course load reduction, priority seating, or help with registration.

6.6 Guardianship

This section captures when an individual has a court-appointed guardian and the reason or diagnosis for which the guardianship was granted.

Does this individual have a guardianship?
If a person has been found incompetent and has a court-appointed guardian of person, estate, or both, select “Yes.”

If the person has not been found incompetent and does not have a court-appointed guardian of person, estate, or both, select “No.”

Typically, when an individual has a guardian, this is due to a diagnosis that is coded in the A, E, or H categories on the Diagnoses Table.

6.7 I/DD Diagnoses with Onset Before Age 22

This section has a question that only pertains to individuals with A1-A10 diagnosis(es).

Was the onset of at least one of the A1-A10 diagnosis(es) before the age of 22?
If a diagnosis is coded as A1-A10, and if the onset of the condition that caused the diagnosis was prior to age 22, select “Yes.”

If a diagnosis is coded as A1-A10, and if the onset of the condition that caused the diagnosis occurred at age 22 or older, select “No.”

6.8 Expected Duration of Diagnosis and Social Security Disability Determination

Included in this section of the LTCFS are three questions that require a response of either YES or NO.

Question 1. Are the needs that are caused by the individual’s primary and/or secondary diagnosis(es) expected to last more than 90 days? Most short-term injuries (for example, from bone fracture) and a related need for assistance from another person would not be expected to continue beyond 90 days.

Question 2. Are the needs that are caused by the individual’s primary and/or secondary diagnosis(es) expected to last more than 12 months OR does the individual have a terminal illness? For purposes of the LTCFS, a terminal illness is defined as a condition where death is expected within one year.

Question 3. Does the individual have a disability determination from the Social Security Administration? In addition to YES or NO, PENDING may be selected as a response to this question. If a person has a presumptive or final disability determination, the screener should select YES in response to this question. PENDING is the correct response when a final decision has not been made about the level of disability for a person who has applied to the Social Security Administration (SSA) for disability-related benefits.

A child’s disability determination from SSA is valid until they reach 22 years of age. When a young adult who has been participating in the Children’s Long-Term Support Waiver program reaches the age of 18, they often transition to a LTC program that serves adults. Although a rare occurrence, it is possible that a child with a children’s disability determination from SSA may not meet adult disability determination criteria. A child may first apply for an adult disability determination with SSA when they reach 18 years of age.

A lack of disability determination does not affect the person’s level of care determination and functional eligibility, but it may be required to meet the LTC programs’ Medicaid non-financial eligibility requirements.

A person can have a disability determination from SSA and NOT meet the definition for a target group that is eligible for adult LTC programs.

Glossary

 
Last revised July 3, 2024