Revision of the LTC Screening Documents and the Minnesota Long-Term Care Consultation Services Assessment Forms

#09-25-02 Bulletin March 12, 2009 Minnesota Department of Human Services 444 Lafayette Rd. St. Paul, MN 55155 OF INTEREST TO County Directors Social Services Supervisors and Staff Waiver Program Administrators and Case Managers Alternative Care Program Administrators and Case Managers Tribal Health Directors Managed Care Organizations Care Systems Staff ACTION Please use the new forms immediately. The MMIS screens and edits will be effective as of April 14, 2009. EXPIRATION DATE Revision of the LTC Screening Documents and the Minnesota Long-Term Care Consultation Services Assessment Forms TOPIC The LTC screening document (DHS-3427) and the LTC Screening Document Telephone Screening (DHS-3427T) have been revised to include new fields and valid values. The Special Needs Basic Care (SNBC) managed care program has been added to form DHS-3427. The MN Long-Term Care Consultation Services Assessment forms (DHS-3428 and DHS- 3428A) are also revised. PURPOSE Explain changes to the forms and MMIS screens. CONTACT Disability Services Division Resource Center (651) 431-2450, 1-888-968-8463, dhs.resourcecenter@state.mn.us or fax at (651) 431-7447 SIGNED March 12, 2010 LOREN COLMAN Assistant Commissioner Continuing Care Administration

Page 2 I. BACKGROUND Various versions of the LTC screening document form have been in use since 1984. This form is used to document preadmission screening and long term care consultation (LTCC) activities as required under Minnesota Statutes Section 256B.0911 and under federal Omnibus Budget Reconciliation Act (OBRA) legislation (Public Law 101 and 103). It is used to record public programs eligibility determination as well as to collect information about people screened, assessed, or receiving services under home and community-based services programs. Changes to the forms and MMIS screens outlined in this bulletin were necessary to improve the quality of data. New edits were developed or existing edits were revised to support these changes. The MN LTC Consultation Services Assessment Forms (DHS-3428 and DHS-3428A) effective 02/09 were also updated to include the new fields and values and can be found on the DHS website under Documents and Forms (edocs). Attachments A and B are copies of the changed forms that can be retrieved from the DHS website. The effective date of the forms is 02/09. Older versions of the form should no longer be used. Attachment C shows changes to the MMIS screens ALT1 ALT6. These screens will accept the new data as of April 14, 2009. II. PREVIOUS SAVED SCREENING DOCUMENTS When adding a new screening document, edits will post to change a value in a field if the old value is no longer valid. Screening documents previously saved in MMIS will include the new fields with no data. Using activity types 01-04, 06, or 08 will post edits requiring that the field(s) be populated. When using activity types 05 or 07 the new fields will be protected from data entry but edits will not post. III. NEW FIELDS ON THE LTC SCREENING DOCUMENT FORMS The following are new fields: Next NF Visit (Section A) This field will identify the date that a visit is required if the under age 65 consumer refuses the annual visit. Mental Health Targeted Case Manager (Section A) This field is required for a screening with the MnDHO or SNBC program. Current Program License (Section B) Planned Program License (Section B) Both of these fields identify the program license of the housing type. The old Current and Planned Housing fields combined housing and license type values. In some cases, those values are no longer valid for the Housing fields and will be used in these new fields instead. OBRA Level 2 Referral DD Diagnosis (Section B) The paper LTC screening document forms DHS-3427 and DHS-3427T included this field but it was not available on the MMIS screen until now. Hearing (Section C) Communication (Section C)

Page 3 Vision (Section C) These fields are currently on the MN LTC Consultation Services Assessment Forms (DHS-3428 and DHS-3428A) but were not required to be added to the screening document until now. Insulin Dependent (Section C) This is a new field that is also added to the MN LTC Consultation Services Assessment Forms (DHS-3428 and DHS-3428A). It asks the question If you are diabetic how do you control your diabetes? Valid values are: 01 not diabetic; 02 - no insulin required - diet controlled only; 03 oral medications; 04 sliding scale insulin and oral medications; 05 scheduled daily insulin; 06 scheduled daily insulin plus daily sliding scale. Please make a note that an answer will be required in this field and edit 646 will post if it is left blank. Institutional Stays (Section E) The statement in the Professional Conclusions section reads The person is generally frail or experiencing frequent institution stays. The experiencing frequent institution stays is now a separate statement. This field is mandatory in those circumstances in which the completion of Section E is mandatory. Visual Impairment (Section E) This is a new statement that reads The person has a visual impairment not corrected by contacts or glasses. This field is mandatory in those circumstances in which the completion of Section E is mandatory. IV. NEW MAJOR CHANGES TO THE LTC SCREENING DOCUMENT FORMS AND MMIS SCREENS Please refer to Attachments A, B, and C. Attachments A and B can be obtained from the DHS website. Section A: Client Information (ALT1) a. New field Next NF Visit. The purpose of this field is to identify the date of the next annual visit for persons under age 65. The date that is populated is 1095 days after the activity type date of the most recent activity type 04. While the initial visit is mandatory, the annual visit may be delayed up to three years. The field is protected and is automatically populated when using new assessment result 43 NF Visit Every 3 Years. Use this assessment result value with program type 00 or 25 and activity type 07 when the person refuses the annual visit. The previous approved screening document must be an active type 04 with assessment result 18 for MnDHO-NF (program type 25) or activity type 04 with assessment result 04 09, or 18 for program type 00. b. The PAS field is re-titled LTCC Cty. c. Legal Representative Status has new value 11 Health Conservator. It is used for persons age 18 and older. d. New field Mental Health Targeted Case Manager. The purpose of this field is to identify people who are receiving serious and persistent mental illness (SPMI) or

Page 4 serious emotional disturbance (SED) case management while enrolled with the Special Needs Basic Care (SNBC), or Minnesota Disability Health Options (MnDHO) managed care programs. The field is mandatory when the program type is 21, 23 28. Values are Y and N. Section B: Screening/Assessment Information (ALT2) Present at Screening/Assessment field. Value 22 Interpreter now refers to an English interpreter. New value 23 Interpreter, ASL is now available. Reason for Referral field has several changes. Value 01 is to be used to record a change in functional capacity as the reason for the referral. New value 16 is to be used to record a change in health status as the reason for referral. Value 09 identifies a request to relocate to the community from any facility. Value 13 shows the referral is for the annual LTCC assessment for under age 65 consumer. Value 15 records the referral is for MnDHO coordination of new and acute services. Value 17 identifies the transition to housing with services consultation (see bulletin 08-25-08 for more information on the use of value 17). Currently Living With and Planning to Live With fields have a new value 05 for Homeless. Current Housing Type and Planned Housing Type allow only the values shown on the screening document forms. Please make a note of this as some values used in the past are no longer valid, and new value 16 Correctional Facility is now available. The Current Housing Type field will reinitialize each time a new screening document is entered so the field must be re-entered. New fields Current Program License and Planned Program License. These fields identify the program license of the housing type. Some of the values in the previous Current/Planned Housing Type fields identified licenses and were not housing types. Again, please refer to the screening document form for the valid values. Value 11 Institution/NF/Certified Boarding Care, can only be used with program types 00, 19, and 25 for planned program license. The Current Program License field will reinitialize each time a new screening document is entered so the field must be reentered. OBRA Level 2 Referral field will now have a field for a MI (mental illness) diagnosis and a DD (developmental disability) diagnosis referral. The value from the old document will not transfer to this field. Once the fields are populated the values will transfer to the next document. Edit 813 will be checking that if the DD History field = Y, the OBRA Level 2 Referral for DD DX must be a Y. If the TBI History field = Y, the OBRA Level 2 Referral for MI can be a Y or N. If the MI History field = Y, the OBRA Level 2 Referral for MI must be a Y for persons who meet the criteria for serious mental illness (SMI) that is defined on the MI Level 1 form DHS-3426. This Level II screening must be completed prior to the NF or boarding care facility admission.

Page 5 Section C: General Function and History (ALT3) New fields called Hearing, Communication, Vision, and Insulin Dependent. These fields are mandatory for program types 01 12, and 21 28. The fields are also mandatory for program type 00 when the activity type is 02 or 04, the assessment result is 18, and the service plan summary includes 38F (relocation service coordination). The Hearing, Communication, and Vision fields were always on the MN Long-Term Care Consultation Services Assessment forms. The Insulin Dependent field has been added to the MN Long-Term Care Consultation Services Assessment forms. Section D: Screening/Assessment Results (ALT4) The Assessment Result/Exit Date field is now re-titled Effective Date. New value 39 Refusal of Health Risk Assessment. Use this value to record the refusal of the health risk assessment contact by a person enrolled in the Minnesota Senior Health Options (MSHO), Minnesota Senior Care Plus (MSC+), MnDHO NF, or SNBC program. It is used with program types 18, 26, and 28. New value 43 NF Visit Every 3 Years. Use this value to record a refusal of the annual under age 65 NF visit. It is used with program type 00 or 25 and activity type 07. New field called Guardian Choice. This field is not mandatory and should be used if there is a guardian involved. The MN Diagnosis Code field previously used with the Community Alternative Care (CAC) program is now eliminated. Section E: Professional Conclusions (ALT4) The statement The person is generally frail or experiencing frequent institutional stays is now changed to the person is generally frail. The statement The person has a sensorial impairment is now changed to the person has a hearing impairment that with or without correction causes functional limitations. New statement The person is experiencing frequent institutional stays is added. New statement The person has a visual impairment not corrected by contacts or glasses is added. Section F: Waiver/AC Eligibility Criteria (ALT4) New program type 28 SNBC. The following fields are mandatory when using this program type with assessment result 35 (health risk assessment). Use activity types 01 or 02.

Page 6 Section A Section B Section C Section D Section F Birthdate Reasons for Dressing Assessment Program Type Referral Behavior Result Activity Type Current Living Orientation Effective Date Arrangement Activity Type Date Current Self Preservation Housing COS, COR, CFR Hearing (fields are required but will change to match financial worker s entry) LTCC County (must be a health plan code) Communication Legal Representative Primary Diagnosis Secondary Diagnosis DD, MI, and TBI History Mental Health Targeted Case Manager Case Manager NPI/UMPI Vision Medication Management NF Stays The following fields are mandatory when using program types 18, 26, or 28 with assessment result 39 (refusal of the health risk assessment when person will not complete the mandatory fields or person cannot be located). Use activity type 07. Section A Section D Section F Birthdate Assessment Program Type Result Activity Type Effective Date Activity Type Date COS, COR, CFR (fields are required but will change to match financial worker s entry)

Page 7 LTCC County (must be a health plan code) Mental Health Targeted Case Manager (not for MSHO or MSC+) Case Manager NPI/UMPI Section G: Service Plan Summary (ALT5) Values 09, 21, 26, and 30 are re-titled. Values 17 and 48 are eliminated. Note that this section is now sorted in alpha order. There are new values. None of these values can be used with the source indicator C (customized or 24-hour customized living). o GRH Room/Board Payment o PCA Supervision o Cognitive Rehab Therapies o Service Animal o Blind/Vision Loss Service o Respite Care Out-of-home o Vehicle Modifications o Adaptive Equipment o Disease Management o Family Training o Adult Protection Services o Child Protection Services o Telemedicine Services o ASL Interpreter o Chemical Health o Private Duty Nursing o Extended Private Duty Nursing o Vent Dependent Section H: Alternative Care Information (ALT6) The AC Lien Referral field is now the Medicare Eligible field. This field is mandatory for program types 09, 10, and 22 and is used to indicate if the Alternative Care person is eligible for Medicare. Values are Y or N. If the value is Y, the Medicare ID Number field must also be completed. Reminder: Edit 739 will post if the Medicare ID number is missing or invalid. When the Medicare ID number field is populated and the Medicare Part A Begin Date and End Date and the Medicare Part B Begin Date and End Date fields are

Page 8 both left blank, the message Correct Highlighted Fields will show at the bottom of the screen. Add the dates to the appropriate field(s). The dates are in the format (using the slashes) mm/dd/yy. If the end date is open ended, put in 99/99/99. V. ATTACHMENTS Attachment A is the LTC Screening Document Form (DHS-3427) http://edocs.dhs.state.mn.us/lfserver/legacy/dhs-3427-eng Attachment B is the LTC Screening Document Telephone Screening Form (DHS-3427T) http://edocs.dhs.state.mn.us/lfserver/legacy/dhs-3427t-eng Attachment C is the revised MMIS Screens ALT1 ALT6 Updated DHS forms are always available on edocs on the DHS website under Publications at http://www.dhs.state.mn.us VI. SPECIAL NEEDS This information is available in other forms to persons with disabilities by calling (651 431-2500), or contact us through the Minnesota Relay Service at 1 (800) 627-3529 (TTY) or 1 (877) 627-3848 (speech-to-speech relay service).

ATTACHMENT C MMIS ALT1 ALT6 SCREENS NEXT: ALT2 01/26/09 12:33:53 MMIS LTC SCREENING - ALT1 01/26/09 DOCUMENT NBR: DOC STAT: CURR LOC/DT: OVERRIDE LOC: CLIENT NAME/ID: REF NBR: AGE: LA: DATE SUB: 012609 DOB: SEX: REF DATE: NEXT NF VISIT: ACTIVITY TYPE: ACT DT COS: COR: CFR: LTCC CTY: LEGAL REP STAT: PRIMARY DIAG: SECONDARY DIAG: DD DIAGNOSIS HISTORY: DD DIAGNOSIS: MI DIAGNOSIS HISTORY: MI DIAGNOSIS: TBI DIAGNOSIS HISTORY: TBI DIAGNOSIS: MENTAL HEALTH TARGETED CASE MANAGER: CM/HP NAME: CM/HP NBR: LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST NEXT: ALT3 01/26/09 12:40:57 MMIS LTC SCREENING - ALT2 01/26/09 DOCUMENT NBR: DOC STAT: AGE/LA: PRESENT AT SCRNG: MARITAL STATUS: REASONS FOR REF: CURRENT LA: PLANNED LA: TEAM: HOSP TRNF: OBRA LVL 1 SCR: PAS 30 DAY: CURR HOUSING: PLANNED HSNG: CURR PGM LIC: OBRA LVL 2 REF - MI DX: DD DX: PLAN PGM LIC: TBI/CAC REF:

NEXT: ALT4 01/26/09 12:45:22 MMIS LTC SCREENING - ALT3 01/26/09 DOCUMENT NBR: DOC STAT: AGE/LA: DRESSING: GROOMING: BATHING: EATING: BED MOB: TRANSFER: WALKING: BEHAVIOR: TOILET: SPC TRMT: CL MONITOR: NEURO DX: CASE MIX: ORIENT: SLF PRES: DIS CERT: SLF EVAL: HEARING: COMM: VISION: MENT ST EV: TEL ANS: TEL CALL: SHOPPING: PREP MLS: LT HOUSE: HY HOUSE: LAUNDRY: MGMT MEDS: INSULIN: MONEY MT: TRANSP: FALLS: HOSP: ER VISITS: NF STAYS: LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST

NEXT: ALT5 01/26/09 12:48:16 MMIS LTC SCREENING - ALT4 01/26/09 DOCUMENT NBR: DOC STAT: AGE/LA: ASSESSMENT RESULTS/EXIT RSNS: EFFECTIVE DT: INFORMED CHOICE: CLIENT CH: GUARDIAN CH: FAM CH: LTCC/IDT RECMND: LVL OF CARE: NF TRACK: CASE MIX AMT: CASE MIX APP (Y/N): REASONS FOR INSTITUTIONAL STAY: ADL COND: IADL COND: COMP COND: COGNITION: BEHAVIOR: HYG/SAFETY: NEG/ABUSE: FRAILTY: INST STAYS: HEARING IMP: REST/REHAB: UNSTABLE: SPEC TREAT: CMPLX CARE: VISUAL IMP: REQUIRES AC/WVR SVC: SAFE/COST EFFECTIVE: NO OTHER PAYOR IS RESP: PROGRAM TYPE: MNDHO RCC: CDCS: CDCS AMOUNT: LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST NEXT: ADHS 01/26/09 12:52:33 MMIS LTC SCREENING - ALT5 01/26/09 DOCUMENT NBR: DOC STAT: AGE/LA: CODE IND DESCRIPTION CODE IND DESCRIPTION LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST

NEXT: ADHS 01/26/09 12:54:39 MMIS LTC SCREENING - ALT6 01/26/09 DOCUMENT NBR: DOC STAT: AGE/LA: STREET ADDRESS: STREET ADDRESS: CITY: STATE: ZIP CODE: CFR: GROSS INCOME: AC ADJUSTED INCOME: GROSS ASSETS: AC ADJUSTED ASSETS: MEDICARE ID NUMBER: MEDICARE PART A BEGIN DT: MEDICARE PART B BEGIN DT: END DT: END DT: AC PREMIUM WAIVER REASON: MED ELIGIBLE: AC PREM ASSESSED: LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST