RFP 240000001827 - Attachment C - LOCD Field Definitions Guidelines.pdf

Michigan Department of Health and Human Services

Michigan Medicaid Nursing Facility Level of Care Determination Field Definition Guidelines

Michigan Medicaid Nursing Facility Level of Care Determination 9/2015 Field Definition Guidelines Page 1 of 18

To access the Michigan Medicaid Nursing Facility Level of Care Determination, you must first complete a one-time registration process with Michigan's Single Sign-on system located at https://sso.state.mi.us. Instructions for registration are located in the User Manual at www.michigan.gov/medicaidproviders >> Prior Authorization >> Michigan Medicaid Nursing Facility Level of Care Determination.

Fields One through Seven Applicant and Provider Information

Field 1: Applicant's Name

Enter the full name of the applicant in the following order: last name, first name, and middle initial.

Field 2: Medicaid ID

Enter the Medicaid identification number in this field when known. The system will not allow billing for this applicant until this field is completed with a valid Medicaid beneficiary identification number.

Field 3: Date of Birth

Enter the applicant's date of birth in the following format: MM/DD/YYYY.

Field 4: Provider Type

Enter the organization provider type.

PACE

Nursing Facility Inpatient CMCF Hospital LTCF Vent/Swing Bed Unit MI Choice Waiver Program

Field 5: Medicaid ID

Enter the Medicaid provider number.

Field 6: Provider Contact Name

List the agency contact person for the applicant in the following order: last name, first name.

Field 7: Provider Day Phone

List the phone number for the contact person for this applicant.

http://www.michigan.gov/medicaidproviders

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Fields Eight through Thirty-One Door 1: Activities of Daily Living

Most applicants who qualify for the Michigan Medicaid nursing facility level of care criteria will qualify under Activities of Daily Living (ADL). This set of criteria has been designed to identify those applicants with a significant loss of independent function.

An individual can vary in ADL performance from day to day. It is important to capture the total picture of ADL performance over a 7-day period. The 7-day period look-back is based on the date of eligibility determination. Information should be obtained from multiple sources when available. Since accurate coding is important for making eligibility decisions, be sure to consider each activity definition fully.

The wording used in each coding option reflects real life situations where slight variations are common. When variations occur, the coding ensures that the applicant is not assigned to an excessively independent or dependent category. Codes permit one or two exceptions for the provision of additional care before the applicant is categorized as more dependent.

To evaluate the applicant’s ADL performance, begin by observing physical tasks. Talk with the applicant to ascertain what he/she does for each ADL activity, as well as the type and level of assistance by others. Also, talk with family members and others when possible and weigh all responses to determine a consistent picture of ADL performances. The following list provides general guidelines for recording accurate ADL self-performance.

~~ Guidelines for ADL Performance ~~

• Do not confuse an applicant who is totally dependent in an ADL activity with one where the activity itself is not occurring. For example, an applicant who receives tube feedings and no foods or fluids by mouth is engaged in eating, and must be evaluated under the eating category for his/her level of assistance in the process.

• An applicant who is highly involved in providing him/herself a tube feeding is not totally dependent and should not be coded as "total dependence," but rather as a lower code depending on the nature of help received from others.

• Each of the ADL performance codes is exclusive; there is no overlap between categories.

Changing from one category to another demands an increase or decrease in the number of times help is provided.

EXAMPLE CODE

Bed Mobility:

Mrs. P has been alone without informal support in the community for the last two weeks and is unable to physically turn, sit up or lay down in bed on her own. She presents with stage 3 pressure sores related to the lack of personnel to assist.

Activity Did Not Occur

Transfers:

Mr. Q routinely sleeps in his reclining chair. He is able to maintain his body position as desired, although he doesn't physically turn to his side.

Independent

Transfers:

Mrs. B is ventilator dependent and, because of many new surgical sites, she must remain on total bed rest.

Activity Did Not Occur

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EXAMPLE CODE

Toileting:

Mr. K has a urinary catheter. Adult briefs are utilized, checked and changed every three hours.

Total Dependence

Eating:

Mrs. D is fed by a feeding tube. No food or fluids are consumed through her mouth tube; feeding assistance is performed by caregivers.

Total Dependence

Eating:

Mr. F is fed via parenteral IV and requires total assistance in maintaining nutrition and fluids through the line.

Total Dependence

Bed Mobility

This section refers to the applicant's ability to move to and from a lying position, to turn side to side, and to position the body while in bed. The 7-day look-back period is based on the date of eligibility determination.

Field 8: Independent

Select this box when the applicant is independent. Independent means the applicant needs no help or oversight, OR help or oversight was provided only 1 or 2 times in the last 7 days.

Field 9: Supervision

Select this box when the applicant required oversight, encouragement or cueing 3 or more times during the last 7 days, OR supervision 3 or more times plus physical assistance provided only 1 or 2 times during last 7 days.

Field 10: Limited Assistance

Select this box when the applicant is highly involved in the activity, received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3 or more times, OR additional help was provided only 1 or 2 times during last 7 days.

Field 11: Extensive Assistance

Select this box when the applicant performed part of activity over last 7-day period, and help of the following type(s) was provided 3 or more times:

• Weight-bearing support

• Full performance by another individual during part, but not all, of last 7 days

Field 12: Total Dependence

Select this box when the applicant required full performance of activity by another individual during entire 7-day period.

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Field 13: Activity did not occur during entire 7-day period (regardless of ability).

Select this box when the activity did not occur for this applicant.

Transfers This section refers to the applicant's ability to move between surfaces, to/from a bed, chair, wheelchair, and to a standing position (excluding to/from bath/toilet). The 7-day look-back period is based on the date of eligibility determination.

Field 14: Independent

Select this box when the applicant is independent. Independent means the applicant needs no help or oversight, OR help or oversight was provided only 1 or 2 times in the last 7 days.

Field 15: Supervision

Select this box when the applicant required oversight, encouragement or cueing 3 or more times during the last 7 days, OR supervision 3 or more times plus physical assistance provided only 1 or 2 times during last 7 days.

Field 16: Limited Assistance

Select this box when the applicant is highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3 or more times, OR additional help was provided only 1 or 2 times during last 7 days.

Field 17: Extensive Assistance

Select this box when the applicant performed part of activity over last 7-day period, and help of the following type(s) was provided 3 or more times:

• Weight-bearing support

• Full performance by another individual during part, but not all, of last 7 days

Field 18: Total Dependence

Select this box when the applicant required full performance of activity by another individual during entire 7-day period.

Field 19: Activity did not occur during entire 7-day period (regardless of ability).

Select this box when the activity did not occur for this applicant.

Toilet Use

This section refers to how well the applicant uses the toilet room (or commode, bedpan, urinal), transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, and adjusts clothes.

The 7-day look-back period is based on the date of the eligibility determination.

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Field 20: Independent

Select this box when the applicant is independent. Independent means the applicant needs no help or oversight, OR help or oversight was provided only 1 or 2 times in the last 7 days.

Field 21: Supervision

Select this box when the applicant required oversight, encouragement or cueing 3 or more times during the last 7 days, OR supervision 3 or more times plus physical assistance provided only 1 or 2 times during last 7 days.

Field 22: Limited Assistance

Select this box when the applicant is highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3 or more times, OR additional help was provided only 1 or 2 times during last 7 days.

Field 23: Extensive Assistance

Select this box when the applicant performed part of activity over last 7-day period, and help of the following type(s) was provided 3 or more times:

• Weight-bearing support

• Full performance by another individual during part, but not all, of last 7 days

Field 24: Total Dependence

Select this box when the applicant required full performance of activity by another during entire 7-day period.

Field 25: Activity did not occur during entire 7-day period (regardless of ability).

Select this box when the activity did not occur for this applicant.

Eating

This section refers to how the applicant eats and drinks (regardless of skill and includes intake of nourishment by other means, e.g., tube feeding, total parenteral nutrition). The 7-day look-back period is based on the date of the eligibility determination.

Field 26: Independent

Select this box when the applicant is independent. Independent means the applicant needs no help or oversight, OR help or oversight was provided only 1 or 2 times in the last 7 days.

Field 27: Supervision

Select this box when the applicant required oversight, encouragement or cueing 3 or more times during the last 7 days, OR supervision 3 or more times plus physical assistance provided only 1 or 2 times during last 7 days.

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Field 28: Limited Assistance

Select this box when the applicant received physical help in guided maneuvering of limbs or other assistance 3 or more times, OR additional help was provided only 1 or 2 times during last 7 days.

Field 29: Extensive Assistance

Select this box when the applicant performed part of activity over last 7-day period, and help of the following type was provided 3 or more times:

• Full performance by another individual during part, but not all, of last 7 days

Field 30: Total Dependence

Select this box when the applicant required full performance of activity by another during entire 7-day period.

Field 31: Activity did not occur during entire 7-day period (regardless of ability)

Select this box when the activity did not occur for this applicant.

Scoring for Door 1 – Activities of Daily Living

Fields Thirty-Two through Forty-One Door 2: Cognitive Performance

The Michigan nursing facility level of care definition is meant to include applicants who need assistance based on cognitive performance. Door 2 uses the Cognitive Performance Scale to identify applicants with cognitive difficulties, especially difficulties with short-term memory and daily decision-making, both essential skills for residing safely in the community.

The applicant’s ability to remember, think coherently, and organize daily self-care activities is very important. The focus is on performance, including a demonstrated ability to remember recent events and perform key decision-making skills.

Scoring Door 1: The applicant must score at least six points to qualify under Door 1.

(A) Bed Mobility, (B) Transfers, and (C) Toilet Use:

• Independent or Supervision = 1

• Limited Assistance = 3

• Extensive Assistance or Total Dependence = 4

• Activity Did Not Occur = 8

(D) Eating:

• Independent or Supervision = 1

• Limited Assistance = 2

• Extensive Assistance or Total Dependence = 3

• Activity Did Not Occur = 8

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Questions about cognitive function and memory can be sensitive issues for some applicants who may become defensive, agitated, or very emotional. These are common reactions to performance anxiety and feelings of being exposed, embarrassed, or frustrated when the applicant knows he/she cannot answer the questions cogently.

Be sure to interview the applicant in a private, quiet area without distraction (not in the presence of others, unless the applicant is too agitated to be left alone). Using a nonjudgmental approach to questioning will help create a needed sense of trust. Be cognizant of possible cultural differences that may affect your perception of the applicant’s response. After eliciting the applicant’s responses to questions, return to the family or specific caregivers as appropriate to clarify or validate information regarding cognitive function over the last 7 days. For applicants with limited communication skills or who are best understood by family or specific caregivers, you would need to carefully consider family insights in this area.

• Engage the applicant in general conversation to help establish rapport.

• Actively listen and observe for clues to help you structure your assessment. Remember:

repetitiveness, inattention, rambling speech, defensiveness, or agitation may be challenging to deal with during an interview, but these behaviors also provide important information about cognitive function.

• Be open, supportive, and reassuring during your conversation with the applicant.

An accurate assessment of cognitive function can be difficult when the applicant is unable to verbally communicate. It is particularly difficult when the areas of cognitive function you want to assess require some kind of verbal response from the applicant (memory recall). It is certainly easier to perform an evaluation when you can converse with the applicant and hear responses that give you clues as to how the applicant is able to think, if he/she understands his/her strengths and weaknesses, whether he/she is repetitive, or if he/she has difficulty finding the right words to tell you what they want to say.

Short Term Memory

The intent of this section is to determine the applicant’s functional capacity to remember recent events (i.e., short term memory).

Process

Ask the applicant to describe a recent event both of you had the opportunity to remember – you can base this on an event or circumstance that you both experienced. After five minutes, ask the applicant about the recent event. Additional methods of assessment include:

• Current season: able to identify the current season (correctly refers to the weather for the time of the year, next legal holiday, religious celebrations, etc.).

• Location of own room: able to locate and recognize own room or home.

• Family and friends names/faces: able to distinguish staff from family or strangers.

• Recent events: ask the applicant to describe the breakfast meal or activity just completed.

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• Recent events: ask the applicant to remember three items (i.e., cook, watch, table) for a few minutes. After you have stated all three items, ask the applicant to repeat them to verify that you were heard and understood. Then proceed to talk about something else

– do not be silent, do not leave the room. After five minutes, ask the applicant to repeat the name of each item. If the applicant is unable to recall all three items, code "memory problem."

If there is no positive indication of memory ability, select Field 33 noting that the applicant has a memory problem.

Field 32: Memory Okay

Select this field when the applicant seems/appears to recall after 5 minutes.

Field 33: Memory Problem

Select this field when the applicant does not recall after 5 minutes.

Cognitive Skills for Daily Decision Making

The intent of this section is to record the applicant’s actual performance in making everyday decisions about the tasks or activities of daily living. This item is especially important for further assessment in that it can alert the assessor to a mismatch between the applicant's abilities and his/her current level of performance, or that the family may inadvertently be fostering the applicant's dependence.

Process

It is suggested that you consult with the applicant first, then, if possible, a family member.

Observations of the applicant can also be helpful. Review events of the last 7 days. The 7-day look-back period is based on the date of the eligibility determination. The inquiry should focus on whether the applicant is actively making his/her decisions, and not whether there is a belief that the applicant might be capable of doing so. Remember, the intent of this item is to record what the applicant is doing. When a family member takes decision-making responsibility away from the applicant regarding tasks of everyday living, or the applicant does not participate in decision making, whatever his/her level of capability, the applicant should be considered to have impaired performance in decision making.

Examples of Decision Making

• Choosing appropriate items of clothing

• Knowing when to go to meals

• Knowing and using space in home appropriately

• Using environmental cues to organize and plan the day (clocks and calendars)

• Seeking information appropriately (not repetitively) from family or significant others in order to plan the day

• Using awareness of one’s own strengths and limitations in regulating the day's events (asks for help when necessary)

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• Knowing when to go out of the house

• Acknowledging the need to use a walker, and using it faithfully

Field 34: Independent

Select this field when the applicant’s decisions were consistent and reasonable (reflecting lifestyle, culture, values); the applicant organized daily routine and made decisions in a consistent, reasonable, and organized fashion.

Field 35: Modified Independent

The applicant organized daily routines and made safe decisions in familiar situations, but experienced some difficulty in decision-making when faced with new tasks or situations.

Field 36: Moderately Impaired

The applicant's decisions were poor; the applicant required reminders, cues, and supervision in planning, organizing, and correcting daily routines.

Field 37: Severely Impaired

The applicant's decision-making was severely impaired; the applicant never (or rarely) made decisions.

Making Self Understood

The intent of this section is to document the applicant’s ability to express or communicate requests, needs, opinions, urgent problems, and social conversation, whether in speech, writing, sign language, or a combination of these (includes use of word board or keyboard).

Interact with the applicant. Observe and listen to the applicant’s efforts to communicate with you. If possible, observe his/her interactions with family.

Field 38: Understood

The applicant expresses ideas clearly and without difficulty.

Field 39: Usually Understood

The applicant has difficulty finding the right words or finishing thoughts, resulting in delayed responses. If given time, little or no prompting is required.

Field 40: Sometimes Understood

The applicant has limited ability, but is able to express concrete requests regarding at least basic needs (i.e., food, drink, sleep, toilet).

Field 41: Rarely/Never Understood

At best, understanding is limited to interpretation of highly individual, applicant-specific sounds or body language (i.e., indicates the presence of pain or need to toilet).

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Fields Forty-Two through Forty-Three Door 3: Physician Involvement

Applicants who have significant clinical instability may be appropriate for long-term care programs.

The frequency of health care practitioner visits (exams) and order changes for the applicant are recorded under Door 3. For this section, visits and orders from physician assistants, nurse practitioners, or clinical nurse specialists working in collaboration with the physician should be included. (Do not count visits or orders made while the applicant was hospitalized.)

Physician orders include written, telephoned, faxed, or consultation orders for new or altered treatments in the community setting. Drug renewal orders are not to be considered.

Field 42: Physician Visits

Identify the number of days within the last 14 days that the physician or authorized assistant or practitioner examined the applicant. The 14-day look-back period is based on the eligibility determination date. Do not count emergency room examination. Enter “0” if none.

Field 43: Physician Orders

Enter the number of days the physician or authorized assistant or practitioner changed the applicant’s orders within the last 14 days. The 14-day look-back period is based on the eligibility determination date. Do not include drug or treatment order renewals without change. Enter “0” if none. Physician orders in the emergency room do count.

A sliding scale dosage schedule that is written to cover different insulin dosages depending on laboratory values does not count as an order change simply because a different dose was administered based on sliding scale guidelines.

Do not count visits or orders prior to the last 14 days. If a resident has multiple physicians, and they all visit and write orders on the same day, this must be coded as one day in which a physician visited and one day for an order change.

Orders requesting a consultation by another physician may be counted; however, the order must be related to a possible new or altered treatment.

Scoring Door 2: The applicant must score under one of the following three options to qualify under Door 2.

1. "Severely Impaired" in Decision Making.

2. “Yes” for Memory Problem, and Decision Making is

“Moderately Impaired” or “Severely Impaired."

3. “Yes” for Memory Problem, and Making Self Understood is

“Sometimes Understood” or “Rarely/Never Understood.”

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Scoring Door 3: The applicant must meet either of the following to qualify under Door 3.

1. At least one Physician Visit for examination AND at least four Physician Order changes in the last 14 days, OR

2. At least two Physician Visits for examination AND at least two Physician Order changes in the last 14 days.

Applicants who score in only Door 3 are those who most likely require ongoing assessment and follow-up monitoring. Care planning for these applicants must include restorative nursing interventions and a specific discharge plan. Restorative nursing interventions are discussed in the Michigan Medicaid Nursing Facility Level of Care Determination Process Guidelines.

Fields Forty-Four through Sixty-One Door 4: Treatments and Conditions

Certain treatments and conditions may be a predictor of potential frailty or increased health risk.

These conditions require the applicant’s primary physician’s documented diagnosis in the medical record. Applicants will not qualify under Door 4 when the conditions have been resolved, or they no longer affect functioning or the need for care. It is required that an active restorative nursing and discharge plan be developed and used as the focus for treatment. Unless otherwise noted, score each item for the last 14-day timeframe. The 14-day look-back period is based on the eligibility determination date.

Field 44/45: Stage 3-4 Pressure Sores

Select the 'yes' box if the applicant had Stage 3-4 pressure sores.

Field 46/47: IV or Parenteral Feedings

Select the 'yes' box if the applicant received intravenous or parenteral feedings.

Field 48/49: Intravenous Medications

Select the 'yes' box if the applicant received intravenous medications.

Field 50/51: End-stage Care

Select the 'yes' box if the applicant meets all eligibility requirements for hospice as certified and documented by both the applicant’s primary physician AND the hospice enrollment physician, OR as certified and documented by the hospice enrollment physician.

Field 52/53: Daily Tracheostomy Care, Daily Respiratory Care, Daily Suctioning

Select the 'yes' box if the applicant received tracheostomy care, daily respiratory care, or daily suctioning.

Field 54/55: Pneumonia within the Last 14 Days

Select the 'yes' box if the applicant had pneumonia within the last 14 days AND has associated IADL/ADL needs or restorative nursing care.

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Scoring Door 4: The applicant must score "yes" in at least one of the nine categories and have a continuing need to qualify under Door 4.

Field 56/57: Daily Oxygen Therapy

Select the 'yes' box if the applicant requires daily oxygen therapy which is documented and prescribed as medically necessary by the applicant’s primary physician.

Field 58/59: Daily Insulin with Two Order Changes in the Last 14 Days

Select the 'yes' box if the applicant received daily insulin injections with two or more order changes within the last 14 days.

Field 60/61: Peritoneal or Hemodialysis

Select the 'yes' box if the applicant received peritoneal or hemodialysis.

Applicants who score at Door 4 require ongoing assessment and follow-up monitoring. Care planning for these applicants must include restorative nursing interventions and a specific discharge plan, except for those receiving end-of-life care. Restorative nursing interventions are discussed in the Michigan Medicaid Nursing Facility Level of Care Determination Process Guidelines.

Fields Sixty-Two through Sixty-Seven Door 5: Skilled Rehabilitation Therapies

This section identifies the presence of rehabilitation interventions based on ordered and scheduled therapy service (physical therapy - PT, occupational therapy - OT, speech therapy - ST) needs during the last 7 days. The 7-day look-back period is based on the eligibility determination date.

Speech Therapy

Record the total minutes that speech therapy was administered or scheduled (for at least 15 minutes a day) in the last 7 days. Enter “0” if none or less than 15 minutes daily.

Field 62: Minutes

Record the total number of speech therapy minutes from all disciplines provided in the last 7 days. Do not include evaluation minutes in the total number of minutes.

Field 63: Scheduled Therapies

Enter the estimated total number of speech therapy minutes (across all therapies) that the applicant was scheduled for but did not receive in the last 7 days. Do not include evaluation minutes in the estimated number of minutes.

Occupational Therapy

Record the total minutes that occupational therapy was administered or scheduled (for at least 15 minutes a day) in the last 7 days. Enter “0” if none or less than 15 minutes daily.

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Scoring Door 5: The individual must have required at least 45 minutes of active PT, OT or ST (scheduled or delivered) in the last 7 days and continues to require skilled rehabilitation therapies to qualify under Door 5.

Field 64: Minutes

Record the total number of occupational therapy minutes from all disciplines provided in the last 7 days. Do not include evaluation minutes in the total number of minutes.

Field 65: Scheduled Therapies

Enter the estimated total number of occupational therapy minutes (across all therapies) that the applicant was scheduled for but did not receive in the last 7 days. Do not include evaluation minutes in the estimated number of minutes.

Physical Therapy

Record the total minutes that physical therapy was administered or scheduled (for at least 15 minutes a day) in the last 7 days. Enter “0” if none or less than 15 minutes daily.

Field 66: Minutes

Record the total number of physical therapy minutes from all disciplines provided in the last 7 days. Do not include evaluation minutes in the total number of minutes.

Field 67: Scheduled Therapies

Enter the estimated total number of physical therapy minutes (across all therapies) that the applicant was scheduled for but did not receive in the last 7 days. Do not include evaluation minutes in the estimate number of minutes.

Applicants who score in only Door 5 require ongoing assessment and follow-up monitoring. Care planning for these applicants must include restorative nursing interventions and a specific discharge plan. Restorative nursing interventions are discussed in the Michigan Medicaid Nursing Facility Level of Care Determination Process Guidelines.

Fields Sixty-Eight through Ninety-One Door 6: Behavior

This Door identifies applicants who display repetitive behavioral challenges. For this area, identify whether the applicant has displayed any challenging behaviors in the last 7 days. The 7-day look-back period is based on the eligibility determination date.

Wandering

Wandering describes those applicants who move about (in or out of doors) with no discernible, rational purpose. Individuals who wander may be oblivious to their physical or safety needs.

Wandering behavior should be differentiated from purposeful movement (i.e., a hungry applicant moving about the apartment in search of food). Wandering may be by walking or by wheelchair. Do not include pacing as wandering behavior. Wandering can occur indoors or out of doors.

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Field 68: 0 - Behavior not exhibited in last 7 days

Field 69: 1 - Behavior of this type occurred 1-3 days in last 7 days

Field 70: 2 - Behavior of this type occurred 4-6 days, but less than daily

Field 71: 3 - Behavior of this type occurred daily

Verbally Abusive

This section identifies applicants who threatened, screamed at, or cursed at others.

Field 72: 0 - Behavior not exhibited in last 7 days

Field 73: 1 - Behavior of this type occurred 1-3 days in last 7 days

Field 74: 2 - Behavior of this type occurred 4-6 days, but less than daily

Field 75: 3 - Behavior of this type occurred daily

Physically Abusive

This section identifies applicants who hit, shoved, scratched or sexually abused others.

Field 76: 0 - Behavior not exhibited in last 7 days

Field 77: 1 - Behavior of this type occurred 1-3 days in last 7 days

Field 78: 2 - Behavior of this type occurred 4-6 days, but less than daily

Field 79: 3 - Behavior of this type occurred daily

Socially Inappropriate/Disruptive

This section identifies applicants who made disruptive sounds, noisiness, or screaming, who performed self-abusive acts, inappropriate sexual behavior or disrobed in public, who smeared or threw food/feces, or who hoarded or rummaged through others' belongings.

Field 80: 0 - Behavior not exhibited in last 7 days

Field 81: 1 - Behavior of this type occurred 1-3 days in last 7 days

Field 82: 2 - Behavior of this type occurred 4-6 days, but less than daily

Field 83: 3 - Behavior of this type occurred daily

Resists Care

This section identifies applicants who resisted taking medications or injections, ADL assistance or eating. This applicant may have pushed a caregiver during ADL assistance. This category does not include instances where the applicant has made an informed choice not to follow a course of care;

the applicant has exercised his/her right to refuse treatment and reacts negatively as others try to re-institute treatment.

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Scoring Door 6: The applicant must score under one of the following 2 options to qualify under Door 6.

1. A "yes" for either delusion or hallucinations within the last 7 days.

2. The applicant must have exhibited any one of the following behaviors for at least 4 of the last 7 days (including daily):

Wandering, Verbally Abusive, Physically Abusive, Socially Inappropriate/Disruptive, or Resisted Care.

Signs of resistance may be verbal or physical (i.e., physically refusing care, pushing caregiver away, scratching caregiver).

Take an objective view of the applicant’s behavioral symptoms. The coding for this item focuses on the applicant's actions, not intent. The fact that family members may have become used to the behavior and minimize the applicant's presumed intent is not pertinent to this coding. Does the applicant manifest the behavioral symptom or not? This is the test you should use in coding these items.

Observe the applicant or significant others during assessment. Observe how the applicant responds to attempts by family members or significant others to assist his/her care. Consult with family members who provide direct care. Ask if they know what occurred throughout the day and night for the last 7 days.

Field 84: 0 - Behavior not exhibited in last 7 days

Field 85: 1 - Behavior of this type occurred 1-3 days in last 7 days

Field 86: 2 - Behavior of this type occurred 4-6 days, but less than daily

Field 87: 3 - Behavior of this type occurred daily

Problem Conditions

Applicants who need long term care may experience delusions and hallucinations that impact the applicant’s ability to live independently in the community. Applicants who qualify at this door must also meet the PASARR requirements for nursing facility admission if they choose a residential setting for care.

Field 88/89: Delusions (Yes/No)

Select "yes" when the applicant has exhibited delusional thinking within the last 7 days.

Field 90/91: Hallucinations (Yes/No)

Select "yes" when the applicant has clearly demonstrated having experienced hallucinations within the last 7 days.

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Scoring Door 7: The applicant must be a current participant, demonstrate service dependency, and meet all three criteria to qualify under Door 7.

Field Ninety-Two through Ninety-Three Door 7: Service Dependency

This section refers to applicants who are currently residents of a Medicaid-certified nursing facility, or a current participant in Ml Choice, PACE or Ml Health Link. Door 7 consists of three criteria. All three criteria must be met to qualify under Door 7. The 'One Consecutive Year' requirement is defined as being a resident of a Medicaid Certified Nursing Facility or participant of Ml Choice, PACE or Ml Health Link for at least one year. You may combine time across these programs; however, there cannot be a break in coverage between, or during, the beneficiary’s stay.

One Consecutive Year Example: NF resident January 1, 2014, through June 25, 2014, then a Ml Choice participant June 26, 2014, through September 7, 2014, then a PACE participant September 8, 2014, through January 3, 2015. The One Consecutive Year is not met if there was one day within the past 365 days the beneficiary was not in any of the above programs or facility.

If service needs can be met by other programs, such as Home Help, the beneficiary does not qualify under Criteria Number 3 below.

Field 92: Does Meet ALL of the Following Three Criteria (select this option ONLY if

ALL of the following are met)

1. Participant for at least one consecutive year (no break in coverage)

2. Requires ongoing services to maintain current functional status

3. No other community, residential or informal services are available to meet the applicant's needs (i.e., only the current setting can provide service needs).

Field 93: Does Not Meet ALL of the Following Three Criteria

1. Participant for at least one consecutive year (no break in coverage)

2. Requires ongoing services to maintain current functional status

3. No other community, residential or informal services are available to meet the applicant's needs (i.e., only the current setting can provide service needs).

Fields Ninety-Four through One Hundred Fourteen Freedom of Choice Form

Field 94: Applicant's Name

The full name of the applicant will be automatically generated. If a beneficiary's number was entered, that number will also be generated following the applicant's name.

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Field 95: Date of Birth

The applicant's date of birth will be automatically generated.

Field 96: Representative's Name

Enter the full name of the applicant's representative, if applicable.

Field 97: Date of the LOCD

The date of the LOCD will be automatically generated.

Field 98: Does Meet Functional/Medical Eligibility

This box will be automatically selected if the applicant meets the functional/medical eligibility for Medicaid LTC programs.

Field 99: Door Number

The Door Number the applicant qualified under will be automatically generated.

Field 100: Does Not Meet Functional/Medical Eligibility

This box will be automatically selected if the applicant does not meet the functional/medical eligibility for Medicaid LTC programs.

Field 101: Signature of Professional Completing LOCD

The health-care professional completing the LOCD on behalf of the applicant must sign the Freedom of Choice form.

Field 102: Title

The health-care professional completing the LOCD on behalf of the applicant must enter their Title on the Freedom of Choice form.

Field 103: Date

The health-care professional completing the LOCD on behalf of the applicant must enter the date they conducted the LOCD on the Freedom of Choice form.

Section II - Freedom of Choice

The health-care professional conducting the LOCD for the applicant must provide information on the program the applicant selects: MI Choice program, nursing facilities, the PACE organization or MI Health Link. The eligible applicant acknowledges via their signature and date that they received information on the program they selected.

Field 104: MI Choice Program

Nursing facilities, PACE and MI Health Link organization use this field to identify referrals to applicants who are interested in the MI Choice Program.

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Field 105: Local Referrals

If the eligible applicant selects nursing facility care as their program of choice, the health-care professional must provide the applicant written referral information for local nursing facilities.

Field 106: Nursing Facility Care

MI Choice programs, PACE and MI Health Link organizations use this field to identify referrals to applicants who are interested in nursing facility care.

Field 107: PACE

Nursing facilities, MI Choice programs and MI Health Link organizations use this field to identify referrals to applicants who are interested in enrolling in to the PACE program.

Field 108: MI Health Link

Nursing facilities, MI Choice programs and PACE organizations use this field to identify referrals to applicants who are interested in enrolling in MI Health Link.

Field 109: Signature of Applicant

The applicant must sign the Freedom of Choice form on the date the LOCD was conducted.

Field 110: Signature of Applicant’s Representative

The applicant's representative, if applicable, must sign the Freedom of Choice form on the date the LOCD was conducted.

Field 111: Date

The applicant, or the applicant's representative (if any), must date the Freedom of Choice form on the date the LOCD was conducted.

Section III - Appeal Rights

Field 112: Signature of Applicant

The ineligible applicant must sign the Freedom of Choice form in acknowledgement of having been advised in writing of his functional/medical eligibility and the right to appeal the LOCD.

Field 113: Signature of Applicant’s Representative

The ineligible applicant's representative, on behalf of the applicant, if applicable, must sign the Freedom of Choice form on the date the LOCD was conducted in acknowledgement of the applicant having been advised in writing of his functional/medical eligibility and the right to appeal the LOCD.

Field 114: Date

The ineligible applicant, or ineligible applicant's representative, if applicable, must date the Freedom of Choice form on the date the LOCD was conducted.