Form 2333, Nursing Facility Risk Criteria Scoring Form

Instructions

Updated: 6/2010

Purpose

The Nursing Facility (NF) Risk Criteria are used to identify individuals who are at risk of NF placement.

Procedure

When to Complete

The case manager completes Form 2333 during the initial face-to-face interview with the individual and/or responsible party when assessing an individual for program eligibility. Form 2333 is completed at the time of the initial application for services and prior to authorization of the pre-enrollment home health assessment.

The risk criteria are not applied to individuals transferring from an NF or the Medically Dependent Children Program (MDCP).

Transmittal

The case manager files the original copy in the individual's case record as part of the eligibility documentation.

Form Retention

The case manager keeps the original in the individual's record for five years after services are terminated.

Detailed Instructions

How to Interview

The case manager will contact the individual to schedule a home visit appointment. It is advisable to ask that the primary caregiver or other knowledgeable individual be present in order to clarify and verify responses of the individual. On the day of the scheduled appointment, the case manager should call to confirm the appointment and to ask if the individual is feeling well enough to have a visit. If the individual is not feeling well enough to receive a guest in his home, the home visit should be rescheduled for a more appropriate time.

When conducting the home visit, the case manager must consider the order in which the factors are discussed. There must be consideration of cognitive status and communication skills of the individual. There is also a need to be sensitive to the person's reaction to the interview and his volunteered responses to other questions. The flow of the questions for the following risk factors may need modifying to accommodate such needs. Although the individual should be the primary informant, it is advisable to request that the primary caregiver or other knowledgeable person be available during the interview in order to confirm or validate any questionable responses from the individual.

The following guidelines are provided as a way of identifying risk factors. Do not read the questions off the form. Use the prompts as provided below.

I. Identifying Data

1. Individual's Name— Enter the individual's last name and then first name.

2. Medicaid No.— Enter the individual's Medicaid number, if known.

3. Responder, if Different from individual— Enter the name of the person who is responsible for the answers during the interview.

4. Responder's Relationship to Individual— Enter the relationship of the responder to the Individual (for example, self, daughter, son, niece).

II. Risk Factors (Identification and Scoring)

The following types of information will be explained for each risk factor in order to facilitate completion and scoring of the risk factors.

Intent: Reasons for including the item in the questioning process.

Definition: Explanation of some key terms.

Prompts: Questions/methods for determining the correct response for each risk factor. Sources include:

• individual interview and observation; and
• discussion with individual's informal and formal support system.

Scoring: Proper method of recording the individual's response to the questioning process.

Risk Factors:

1. Prior Nursing Home Placement

Intent: To identify if the individual has a history of NF placement within the last five years.

Definition: Lived in an NF— Prior stay in one or more NFs excluding limited stays for treatment or rehabilitation.

Prompt: Find out from the individual if he had lived in an NF in the last five years.

Scoring: Check "Yes" if answers yes to living in an NF during the past five years based on the above definition.

Check "No" if answers no.

2. Neurological Diagnosis

Intent: To determine if the individual has one or more of the neurological conditions.

Definition: Dementia other than Alzheimer's Disease— Includes diagnoses of organic brain syndrome (OBS) or chronic brain syndrome (CBS), senility, senile dementia, multi-infarct dementia and dementia related to neurologic diseases other than Alzheimer's (for example, Picks, Creutzfeld-Jacob, Huntington's disease).

Head Trauma— Wound or injury to head, often caused by traffic or other accidents, that can cause language impediment, seizures, amnesia, functional impairments and behavioral changes. Brain tumors and cerebrovascular accidents (strokes) are also included in this category as they involve internal injury to living brain tissue which causes symptoms similar to those seen in external head trauma.

Parkinsonism— Group of neurological conditions characterized by tremor, muscle rigidity, abnormal mobility and difficulty swallowing.

Alzheimer's— Dementia (an organic mental syndrome characterized by a general loss of intellectual abilities involving impairment of memory, judgment and abstract thinking as well as changes in personality) of slow onset and gradually progressive course, occurring in almost all cases after the age of 50.

Multiple Sclerosis— A central nervous system disease presented by weakness, incoordination, paresthesia (abnormal touch sensations, such as burning, prickling), speech disturbances and visual complaints.

Prompt: Find out from the individual if he is being seen and treated by his physician for any of the diagnoses as defined above.

If an individual claims a neurological diagnosis, enter a check in front of the diagnosis.

Scoring: Check "No" if no diagnosis is self-reported.

For individuals with a self-reported diagnosis:

• If the diagnosis can be verified, check "Yes"; if not verified, check "No."
• If the individual only meets this risk factor, and it has not been verified at this time, check "No."

3. Goes Out One or Fewer Days a Week

Intent: To determine one's stamina. If below a certain threshold of activity, functional decline may be accelerated.

Definition: Goes out one or fewer days a week— Going out (leaving) of one's house. One's house includes the porch and patio area.

Prompt: Find out from the individual if he is able to leave his house to go out. Is he able to go out of his house only to sit on his porch or patio or does he leave the premises more than once per week? If weather prohibited leaving the house, ask the question based on a typical seven-day period during another part of the month.

Scoring: Check "Yes" if the individual states he only goes out of his house to his porch or patio area with or without the assistance of others regardless of how many times he goes out. The porch, patio area is considered an extension of one's house. Individuals who only leave their residence to go to medically necessary physician appointments, therapy service or dialysis are considered to go out of their house one or fewer days a week. Therefore, check "yes" if the individual goes out only to medically necessary physician appointments. Additionally, individuals who only go out to access outside bathrooms are considered to go out one or fewer days a week, therefore, check "yes."

Check "No" if the individual states he goes out of his house into his yard or off his premises to play Bingo more than one time in the last seven days or if he indicates he doesn't have any trouble leaving his premises.

4. Fall History

Intent: To determine the individual's risk of future falls or injuries. Falls are a common cause of morbidity and mortality among elders.

Definition: Falls— An unintentional change in position where the individual ends up on the floor or ground. A stumble (where balance is regained and the individual does not end up on the floor) does not count as a fall.

Prompt: Find out if the individual experienced any falls in the last six months and if so, how many? The case manager does not need to know the reason for the fall.

If an individual states he almost fell but caught himself on the arm of the chair and eased down onto the floor, count this as a fall.

Scoring: Check "Yes" if the individual states he had two or more falls in the last six months.

Check "No" if the individual stated he fell only one time or had no falls in the last six months.

5. ADL Deficits

Intent: To record the individual's need for assistance in performing his activities of daily living (ADL) during the last seven days.

Definitions:

Hands-on guidance— Guided maneuvering of limbs or other non-weight bearing assistance needed for maintaining balance when transferring. (Resident highly involved in activity.)

Actual physical assistance— Weight bearing support of extremities provided or full dependence on another for part or all ADL performance.

Supervision— Oversight, encouragement or cuing.

Note: An individual's ADL self-performance or need for assistance may vary from day to day, or within days. There are many possible reasons for these variations, including mood, medical condition, relationship issues (for example, willing to perform for a daughter he or she likes but not the son), medications, alcohol consumption, etc. The case manager is to consider the individual's need for assistance over the last seven day period, 24 hours a day, not only how the case manager observes the individual on the day of the interview.

Prompt: Determine what, if any, and the type of assistance received in performing the ADLs of dressing, personal hygiene, eating, toilet use and bathing. Assistance may have been obtained from personal care attendants, family or other informal support.

Scoring: Check "Yes" if the individual received any hands on guidance or any type of physical assistance in dressing, personal hygiene, eating or toilet use on at least three occasions during the last seven days as identified by a check in front of the ADL or if the individual received any assistance including supervision provided three or more times during the last seven days for bathing as indicated by a check in front of bathing.

Check "No" if assistance or supervision was not needed on at least three occasions during the last seven days.

Definitions of ADL's

1. Dressing: How an individual puts on, fastens and takes off all items of street clothing, including donning/removing a prosthesis.
2. Personal hygiene: How an individual maintains personal hygiene, including combing hair, brushing teeth, showering, applying makeup and washing/drying face, hands and perineum. Exclude washing of back and hair.
3. Eating: How an individual eats and drinks, regardless of skill, includes intake of nourishment by other means (for example, tube feeding, total parenteral nutrition).
4. Toilet Use: How an individual uses the toilet room commode, bedpan or urinal, transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter and adjusts clothes.
5. Bathing: How an individual takes a full-body bath/shower, sponge bath and transfers in/out of tub/shower. Excludes washing of back and hair.

Do Not Include Set-Up Help

Set-up help is the type of help characterized by providing the individual with articles, devices or preparation necessary for greater resident self-performance in an activity. This can include giving or holding out an item that the individual takes from the care provider.

Examples of Set-Up Help

For dressing: Retrieving clothes from closet and laying out on the bed, handing the individual his shirt.

For eating: Cutting meat and opening containers at meals, giving one food category at a time.

For personal hygiene: Providing a wash basin and grooming articles.

For bathing: Placing bathing articles at tub side within the individual's reach; handing the individual a towel upon completion of a bath.

For toilet use: Handing the individual a bedpan or placing articles necessary for changing ostomy appliance within reach.

Check the following ADLs if any assistance (from hands-on guidance to the actual physical assistance) was received on at least three occasions during the last seven days for dressing, personal hygiene, eating or toileting. (If an individual is receiving personal attendant hours, he is receiving some assistance with his ADLs.)

Check the ADL bathing if any assistance, including supervision, was received on at least three occasions during the last seven days.

Case Examples of Assisted ADLs

An attendant visits each morning to provide physical weight bearing help with dressing. Later each day, the individual feels better (joints were more flexible), she required assistance only to undo buttons and guide her arms in/out of sleeves every p.m.

Individual has difficulty initiating the eating process. She always ate independently after someone guided her hand with the first few bites and then offered encouragement to continue.

Individual fed self her own breakfast and lunch but tired later in day. She was fed totally by her daughter at the supper meal.

Individual has Alzheimers and is incontinent. She can be maintained dry most of the time if she is taken to the toilet. Someone has to stay with her during the toilet process, clean her and adjust her clothes.

Individual performed all tasks of personal hygiene except shaving. Because of poor eyesight, his wife shaves his thick beard three times a week.

Individual received verbal cuing and encouragement to take twice-weekly showers. Once son walked individual to bathroom, he showered with periodic oversight.

Individual receives help in transferring into tub and attendant guided individual in bathing himself 3x/week. (If Individual helped himself in/out of tub 2x/week and only received help 1x/week, it would not be considered assisted.)

6. Urine Incontinence

Intent: To determine if the individual had two or more episodes of urine incontinence daily over the last 14 calendar days.

Definition: Urine incontinence— Involuntary loss of urine causing wetting of one's clothes or requiring pads/diapers daily.

If an individual has an indwelling Foley catheter in place or a propped urinal and is dependent on others to be maintained dry, he meets the criteria.

Prompt: Find out from the individual if he has accidents (lack of control over bladder is such that he has to wear pads to keep from wetting his clothes). If "yes," ask how often? How many times a day?

Scoring: Check "Yes" if the individual states he has two or more episodes of urine incontinence daily within the last 14-calendar day period or if an individual is being maintained dry with an indwelling catheter changed by others or a propped urinal placed by others. (Identify this as a "yes" even if the individual started having multiple episodes of urine incontinence just several days ago. It does not have to be a permanent change in condition or to have been going on for 14 calendar days to count.)

Check "No" if the individual states he has bladder control but is sometimes (less than daily) incontinent but has not been incontinent two or more times daily over the last 14-calendar day period.

7. Functional Decline

Intent: To determine a decline in the individual's overall functional status over the past 90 days. (Has the individual's condition deteriorated in that he needs more support today than he did 90 days ago?)

Definition: Functional status— Includes self-care performance and support, continence patterns, use of treatments, etc.

Prompt: Find out from the individual if he is able to do as much care for himself today as he did three months ago or has he experienced any recent functional declines.

Scoring: Check "Yes" if it is determined by the case manager that the individual's physical condition significantly changed his overall self-sufficiency or self-care performance within the last 90 days. Just having the individual alone say he has had a functional decline does not qualify for a "Yes" on this risk factor. The case manager may need to verify this by reviewing the need for additional attendant care or nursing services in the last few months and/or find out from the family/support system any additional demands they may have encountered.

Individuals with a recent loss of ability in meal preparation, housekeeping, laundry or other instrumental activities of daily living are not considered to have a functional decline.

Check "No" if it is determined that the individual's self-sufficiency and overall care needs have not changed.

Examples: These examples may not apply to every individual and may need to be adapted to fit the individual. Ask, "has there been any change in the way you get around in your home?" (Determine how the individual is mobile within his home and if he uses a wheelchair today, ask when he started using the wheelchair? Did he use the wheelchair 90 days ago?) If he uses a walker today, when did he start using it?

Ask, "has your doctor changed your medical treatment in any way, such as new treatments, new medications?" (As an example, if the individual says the doctor has changed his decubitus treatment, ask if it is more involved or lengthy or more time consuming today than before he was rechecked by his physician).

Ask, "has there been a change in your bladder status? Do you have more or less bladder control today than you did before?"

After listening to the individual talk about his functional status, the assessor must make the determination. Did the individual have a functional decline and did it happen in the last 90 days?

Case Example of a Functional Decline

Individual has a several year history of Alzheimer's disease. Although for the past year he was quite dependent on others in most areas, he was able to eat and walk with supervision until recently. In the past 90 days he has become more dependent. He no longer feeds himself. Additionally, he fell two weeks ago and has been unable to learn how to use a walker. He now requires two-person assistance for walking even short distances when before, he could walk alone.

If a functional decline is identified, and it is determined that it did occur within in the last 90 days, enter, as examples, "two months ago, two weeks ago, etc."

If the individual states he had a functional decline, ask him to describe the functional decline and document his response. Some examples would be "I now have to use this wheelchair for getting around in my home." "Ever since I was hospitalized with my bladder infection, I have had to wear diapers, I just don't have any control."

If a functional decline is identified, the case manager enters a rationale.

1. When did it occur?
2. What was the functional decline?
3. Document rationale for identified response:

Examples of Rationale:

• More care and assistance is required.
• Recent fall, less mobile, now using a walker.
• One month ago was independent with bathing, now requires assistance in bathing.
• More family time and involvement in individual's personal care.

If a functional decline is not identified, enter any comments pertinent or enter "not applicable." An example of a pertinent comment regarding the rationale for not identifying a decline, "My daughter tells me I am much worse today than I was three months ago and insists that I need more help. I don't feel that way." (After talking to her, the daughter agreed that her father is really about the same.)

III. Comments

This section is to support the score.

Enter any pertinent observations from the visit, such as "individual ambulatory without his walker to answer the phone across the room but told me he had to use his walker or he couldn't walk."

IV. Eligibility/Non-eligibility Status

Enter a check if fewer than two "yes" identified. The individual does not meet the risk factor criteria. Send a denial notice.

1. Enter a check if two or more "yes" identified. Continue the eligibility process.
2. If the individual does not meet the risk criteria but in the case manager's judgment the individual is at risk of NF placement, the case manager may provide the documentation through the regional director to the waiver section manager for consideration.

Signature of Case Manager and Date— The case manager signs and enters the date the form was completed.