ADRC Assessment ToolsPopulations Covered Older Adults PWD DD Other Approximate Time to Administer

System/Form Name Long Term Care IADL Eligibility Assessment (ULTC 100.2 updated 9/22/03)

Information Elements

Responsible Entity

Administering Staff

Staff Training

Format: Paper/ Automated

Statewide or Local

Programs Covered

Links to Forms

Notes

CO

ADLs, supervision (including: behaviors, cognitive), demographics, environment, risk, advance directives, MI/MR, level of care determination, strengths assessment and evaluation, self reported physical health, LTC plan.

Yes (60+) Yes (18-59)

http://adrctae.org/tikipage.php?pageNa me=ADRC+Toolb ox+Summary#ch5

Federal and State Funded Two assessment tools: 1) Minimum data set-home care (MDS-HC) used for Medicaid waiver programs; and 2) a shorter psychosocial assessment tool for state funded HCBS. It also includes client assessment protocols (CAPS), used to develop care plans. CHAT contains a client evaluation of services and a worksheet to determine client's share of costs (income is self reported). CHAT specialists or Case Managers All staff undergo extensive special staff training to make sure positions for data callers are getting entry, updating and appropriate information. managing theprocess

AutomatedIn home assessments are completed by case managers on laptops

GA

CHAT

Area Agencies on Aging

Yes (60+)

Yes

Varies

Statewide

CHAT software provides assessment by screening clients requesting publicly funded community based Forms unavailable. services provided under Title 3, Social Services Block Grant, the state home care program, CCSP (GA's Medicaid Waiver Program) or SOURCE

CHAT phone screening tool is used to determine appropriateness for a program, maintain waiting lists, and document CM activities. If formal assessment needed, it includes: identification of health problems, other services already in place, DON instrument to measure level of impairment and need. CHAT can also be used for electronic referrals to ARC's CM agencies. MA financial eligibility determination is not a part of the system. CMs take Medicaid applications to inhome appointments but applications are reviewed by AAA staff before being waitlisted. If formal assessment needed, I&A specialist uses CHAT to determine if individual qualifies for publicly funded services. If not eligible, refer them to program and services available for private pay and sends the materials. CHAT is integrated with the ESP program.

IL

Illinois Department on Aging Choices for Care Assessment Form IL-402-1230 (Rev. 12/03)

Demographic Information, Financial Declaration, service selection and applicant/client certification, mini-mental state examination, level of cognitive impairment, State Department determination of need, Financial data, case documentation on Aging for the determination of need (DON, meds, formal/informal supports, special service instructions), physician's name, emergency contact, advance directives.

Certified Case Managers thru IDOA contracted Case Coordination Units are allowed to complete the Choice Assessment Form for CCP or facility placement

Required to attend a Preliminary Training for a temporary certificate good for 6 months. Before the 6 months is complete, they earn a certification card that is good for 18 months. A Recertification class or conference must be attended to extend certification for 18 months.

Papera few forms have been approved for electronic use, the Yes (60+) technical, confidential and fiscal aspects are being excluding reviewed for electronic SMI and DD formatting and a demonstration project using laptops is under consideration

Some CMs also contract with the Office of Rehabilitative Services to conduct hospital based nursing home prescreenings for those under 60 years of age, excluding MI/DD.

1 to 3 hours

Statewide

Federal and State Funded

Forms available from State as requested.

State, Federal, local and private sources Individuals access services by calling one of the 16 AAA offices. Data tracking begins with initial assessment. Once approved for waiver, client can choose CM of their choice who will database to enter following information: demographics, functional assessments, level of care determination, family and community support systems, limitation of ADL's and IADL's, nutrition, consumer goals, planned services, cost/frequency of services authorized, funding sources, initiation and stop dates, quality assurance measures, case notes.including Community and Home Options to Institutional Care for the Elderly and Disabled (CHOICE) program, Title III of the Older American Forms unavailable Act, Social Services Block at this time. Grant, Older Hoosiers Account, Seven Home and Community Based Waivers, Local and Private Funds (provide additional resources for specific services to the elderly and disabled)

IN

INsite

State Division of Disability, Aging and Rehabilitation Services (a unit of the Family and Social Services Administration)

Certified Staff at AAA's, private case management groups, the State Certified by DDARS Aging Bureau, and the State Medicaid unit.

Automated

Yes

Yes

Statewide

INsite: single data management system to collect and track client info for community based services administered by the Division of Disability, Aging and Rehabilitation Svcs or funded by the Office of Medicaid Planning and Policy, both of which are units in the Family and Social Services Administration. INsite is used to conduct nursing home and community based assessments; id providers, manage cases, track eligibility, costs and use of the state-funded CHOICE program, Medicaid waivers, Medicaid state plan services, SSBG, and Older American Act funded services.

ME

Medical Eligibility Determination Tool (MED Ver 5.0 updated 7/1/03)

Background information including identification information; clinical detail including professional nursing services, special treatment and therapies, cognition, problem behavior, physical functioning/structural problems, medications, diagnoses, communication, vision, nutrition, continence, balance, oral/dental, skin conditions, IADLs, environmental, mood; scoring sheets, Community Options Care Plan Summary, outcomes. Identifying information; social functioning; informal support services; environmental assessment; cognitive patterns; mood and behavior patterns; disease diagnoses; disabilities; health conditions; nutritional; dental; vision; skin; continence; physical functioning; service utilization; medications; vitals.

Outside vendoradministration

Bureau of Elder Nurses must have and Adult Services community healthplanning, policy development, coordination, and evaluation experience

Several weeks training at start of employment, then Automated mentoring until can do use laptops at face-to-face meetings assessment indpendently (about 6 months).

Adults 18+ who want access either to NF admission or Community LTC programs.

.75 hours to 2 hours

Statewide

State general funds; http://www.state.me State is in process of developing specialized Medicaid State Plan and .us/dhs/beas/medx assessment tool that expands psychiatric/mental Medicaid HCBS health areas in the tool. x_me.htm

MI

MI Choice Care Management Assessment (ver 1.4.0.0. updated 3/30/00)

Both blank forms capture Local Waiver Agencies Social Worker and Training in assessment Nurse completion protocol.information, which is scanned into MIS that is financially supported by the waiver agencies

Yes (65+) Yes (18-64)

1.5 - 2 hours

Statewide

State and Federal Medicaid Waivers

Forms unavailable at this time.

MN

Minnesota LongTerm Care Consultation Services Assessment Form: SW Section (DHS3428A updated 11/03) and PHN Section (DHS3428A updated 10/04)

Both LTC assessment forms are SW Section: Assessment activity information; client information; informant information; comments; caregiver support/social resources; emotional and mental health; self preservation and safety; results; service plan summary; LTC assessment form. PHN Section: Health assessment; ADLs; IADLs; caregiver assessment. Training provided by policy staff from Aging and Adult Services section of DHS; training provided to new workers at least 4 times per year and as requested by county.writeable and mergeable. Long Term Care Consultation staff complete assessments using laptop, then save assessment data electronically for future use and updating, or for merging with electronic version of the LTC screening tool. Some forms available in "readable" format only.

Social Worker or State Department Public Health of Human Services Nurse

Yes

Yes (under 65)

Yes

2 hours

Statewide

State and Medicaid Funded

http://adrctae.org/tikipage.php?pageNa me=ADRC+Toolb ox+Summary#ch5

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ADRC Assessment ToolsPopulations Covered Older Adults PWD DD Other Approximate Time to Administer

System/Form Name

Information Elements

Responsible Entity

Administering Staff

Staff Training

Format: Paper/ Automated

Statewide or Local

Programs Covered

Links to Forms

Notes

NC

CAP/DA Data Set January 2004

Client identification, date/reason for assessment, cognitive status, mood & behavior patterns, communication/ hearing patterns, vision, disease diagnosis, health conditions, Training in local agencies medications, oral/nutritional status, continence, skin Division of Medical Nurses and Social in how to use forms, Automated condition, physical functioning & structural problems (ADLs Assistance conduct assessments, be a web-based Workers & IADLs), special treatments & procedures, home/ case manager. environment, social support, economic status, comments, assessment certification.

Yes

Yes (19-59)

Statewide as Federal and State including care of 7/1/04 fundedplan

5 hours

Use AQUIP program- automated quality and utilization improvement program. Will be webhttp://www.adrcbased forms. Program will produce care plans tae.org/tikidownload_file.php? and generate a lot of statistics for comparable data. Based upon the MDS system used for fileId=385 Nursing Homes.

NJ

NJ EASE Comprehensive Assessment Tool

Section 2: benefits screening, demographics, emergency contact/primary caregiver, primary health care provider, current informal services, living arrangement/physical environment, functional status (ADLs and IADLs), support systems, finances, follow-up outcome, quality assurance. Section 3 (extended assessment): physical health assessment (medical condition/diagnosis), physical health (professional visits), physical health (medications), psychosocial assessment, physical health assessment (physical functioning, communications, hearing, vision, nutrition status, and lifestyle, special treatments and procedures, assistive devices/equipment, caregiver interview, assessment summary.

State Department of Health and Senior Services

Care Managers have a BA or MS in social science or health related field and are licensed or certified as Outreach Workers required by NJ law and/or agency policy. They Section 2 during complete NJ EASE lead home visit and Automated agency orientation and Care Managers mandatory NJ EASE Basic Section 3 during home visit Care Management training within 18 months of becoming a care manager, as well as continuing education.

Yes (60+)

Receiving services through Jersey Assistance for Community Caregiving (JACC), Community Care Program for the Elderly and Disabled (CCPED), or Enhanced Community Options (ECO) Medicaid Waivers

.5 hoursSection 2 by phone 1.5

hoursSection 3 in home

Statewide

State, Federal, including waivers, and county funds

These funds support staff members who function within the system. State money supports ongoing training of the NJ Ease staff and state nursed involved in the NJ EASE project. Federal http://adrcmoney supports nurses doing the PAS and the tae.org/tikipage.php?pageNa care managers working with the waivers. me=ADRC+Toolb County money supports I&A staff, outreach ox+Summary#ch5 workers, care managers, and support staff involved in NJ EASE at the county level, and some local communities support I&A workers in the local senior center.

OR

Oregon Access

Eligibility and care planning, medical (medications, diagnosis, treatments/procedures, durable medical equipment, allergies, health history, pain, and supports); mobility (level of need, equipment, falls, and supports); personal care (eating, special diet, bathing, hygiene, grooming, dressing, skin care and foot care); elimination (toileting, bowel, and bladder); communication (vision, hearing, and speech & language); mental status (cognition/memory, behavior, mood, sleep, losses, suicide, geriatric depression scale, Mini Mental State Exam); household management (phone, housekeeping, laundry, meal prep, financial management, shop, transport, pet care, house/yard); personal elements (alcohol, tobacco, drug, exercise, employment/interests, education, legal, spirituality); environment (physical and community); change log; care planning (calculate needs, ability to pay, cost of services needed, and provider list); assessment type, date and history.

Seniors and People with Disabilities Division, State Department of Human Services

Case Managers

Training to use the nurses do nursing software program. Automated assessment section Provided TA assistance and On laptops in the home if client referred by continued training. case worker

Medicaid clients (65+), Older Americans Act clients (60+), Oregon Project Indpendence clients (60+)

1 hour

Statewide

Medicaid State plan, Medicaid Waiver and State funded services

Hardcopy print screens available as requested to the listed state contact.

TX Texoma Real (Texom Choice Program a AAA) Assessment

Demographic information, income, QMB, SLMB, formal and informal support systems, medical background, advance directive, disability, medications, sensory/communications, Area Agency on nutrition, emotional health, other medical concerns. Aging Separate client needs assessment covers IADLs and ADLs. Separate mental health assessment. Aging and Disability Services Administration astatewide network of Home and Community Services Offices administers the assessment, authorizes services and determines financial eligibility

Care Specialized training for coordinators/ specific job titles. navigators and benefit counselors

Both

Yes (60+)

Yes

Varies

SPE specific State and Federal to this AAA funded

http://www.hcbs.org /moreInfo.php/topic /33/ofs/30/doc/287/ Texoma_Real_Cho ice_

WA

Demographics, environmental, medical, indicators, Comprehensive communication, psychological/social, personal elements, Assessment mobility, toileting, eating, hygiene, household tasks, Reporting functional status, care plan, pending respite, QA Evaluation (CARE) monitoring, history.

Social WorkersMSW or BA + 2 yrs exp. with assessments or Nurses with Masters degree

2 days policy training and Automated 2 days of application use laptops during face-to-face training on the CARE tool. visits

2.5 hours Yes Yesincludes generating a service plan

Statewide

http://www.adrcMedicaid Personal Care tae.org/documents/ and Waiver Programs washcare.pdf

WI

Demographics, residence, ADLs, IADLs, overnight care, Functional Screen employment, diagnoses, health related services, communication, cognition, behaviors-mental health, risk.

Wisconsin Department of Health and Family Services

Experienced professionals who have taken a The screen is adminstered on training course Online training course and the Web and must be entered and have passed a exam. on-line certification exam can administer the screen.

Yes

Yes

Children's Version

Unknown

Statewide

Medicaid Waiver Programs and State Funded Programs

http://www.dhfs.stat e.wi.us/LTCare/Fun ctionalScreen/Pape rFormV3.pdf

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