**Standards for Targeting Individuals at Risk of Nursing Facility
Placement**

***This document was developed in support of AoAs Choices for
Independence Community Living Incentive -- a nursing home diversion
strategy.***

The Community Living Incentive (CLI) gives states and communities
greater flexibility under the Older Americans Act to help prevent or
delay nursing facility placement for moderate and low-income older
adults while promoting consumer directed care options. Access to home
and community-based services (HCBS) can forestall or prevent nursing
facility placement for older adults. Researchers have concluded that a
significant percentage of nursing facility residents could be treated in
lower levels of care. [^1] In almost all cases, states spend less per
person on community services than on nursing facility services.

Nonetheless, maximum cost effectiveness of HCBS programs can remain
elusive if programs do not identify those who would truly otherwise be
in a nursing facility. Only a fraction of the participants in Medicaid
HCBS programs would actually have entered a nursing facility in the
absence of those services. As a result, in order for the Community
Living Incentive to be able to deliver on its promise of preventing
individuals from entering a nursing facility and spending down to
Medicaid eligibility, the method for identifying and targeting
individuals at risk of nursing facility placement becomes critical.

Several studies have concluded that *broadly* expanding access to
facility and community-based services does not reduce public
expenditures for long-term care.[^2] Despite the challenges of achieving
overall cost effectiveness, research suggests expanding well-focused
HCBS programs targeted to people who exhibit potential for substitution
between home and institutional care and for whom the correct mix of
services is provided can reduce costs. [^3] Thus, for the Community
Living Incentive, an applicant's proposed targeting criteria and program
design will be carefully evaluated against the evidence provided by
empirical research. Applicants can also provide their own evidence that
the strategies they will pursue will reduce or slow the growth of
nursing facility utilization.

Generally, research suggests that diversion programs should target
people with the most significant functional and cognitive impairments
because they are the most likely to otherwise enter a nursing facility.
However, functional status alone does not result in the need for nursing
facility care; age, living alone, having an informal caregiver, poor
cognitive status, and prior hospitalizations are all the factors
positively associated with institutionalization.[^4] Also, key to a
"true" diversion is identifying individuals who would have remained in a
nursing facility for an extended period of time, not just for a
post-acute episode (i.e., distinguishing short-stay and long-stay
patients). Using point-in-time assessments, especially at a time of
hospitalization, can also complicate the identification of potential
long stay nursing facility entrants because functional and health status
can change significantly after a few weeks (e.g., individual who suffers
a stroke). As a result, depending on the initial circumstances, it may
be appropriate to reassess individuals to make more accurate
determinations of their risk of institutionalization.

The multiple risk areas can be grouped into four main domains:

1.  **Functional status** which includes ability to perform activities
    of daily living and instrumental activities of daily living.

2.  **Health status** which includes certain diagnoses (e.g., diabetes,
    falls related fractures), medical/skilled needs (e.g., nursing,
    therapies) and can be evidenced by a hospitalization or a prior
    nursing facility stay and the use of medications.

3.  **Cognitive/emotional status** which includes cognitive impairments,
    impairments in decision-making ability, inability to make decisions
    to avoid injury in emergency situations, and depression.[^5]^,^ [^6]

4.  **Informal support** and the amount of burden placed on those
    supports often obtained through a caregiver interview.

In a review of 12 states' assessment instruments, states use outcome
decision criteria that describe how the assessment compares to the
thresholds or eligibility criteria established by the state for the
programs covered by the assessment instrument.[^7] A checklist,
narrative observations of the interviewer, or a combination of both are
used to determine the needs of, and services available to, the consumer.
The eligibility decisions are based on the information obtained during
the assessment process and the state's method for scoring or weighting
items, with some states having developed scoring algorithms to rank
individuals on risk factors associated with nursing facility placement.
States that include medical factors in their criteria consider the type
and frequency of the medical services received. Functional variables are
typically rated as independent, supervision/cueing required, limited
physical assistance, extensive assistance, or totally dependent/does not
perform.

However, most level of care determinations are not based on validated
research that the factors measured predict nursing facility admission.
Research on level of care instruments has focused on inter-rater
reliability and consistency with prior instruments, not necessarily
whether the instrument and scoring are predictive of nursing facility
admission.[^8] As a result, the targeting criteria for the Community
Living Incentive may need to go beyond a state's Medicaid nursing
facility level of care criteria. Despite this, the elements used in most
states' level of care assessments include elements from a British study
that evaluated which elements of three separate assessments best
predicted a nursing facility admission from a hospital (***see insert
box***).[^9]

Some efforts are in progress to develop screening tools to identify
individuals at risk of nursing facility admission. AAA10B in Ohio has
engaged a researcher to develop an instrument that uses a subset of
questions from their Medicaid HCBS waiver assessment that weights these
items and compares them to a cutoff score to identify individuals at
high risk of institutionalization. Eight states base their screening
tool on the RAI Home Care (RAI-HC) which includes a five page tool,
designed to collect standardized information on a broad range of domains
critical to caring for individuals in the community, including items
related to cognition; communication/hearing; vision; mood and behavior;
social functioning; informal support services; physical functioning;
continence; disease diagnoses; health conditions; preventive health
measures; nutrition/hydration; dental status; skin condition;
environment/ home safety; service utilization; medications; and
socio-demographic/background information (***see insert box***). The
tool's ability to predict long term nursing facility admission is
currently being assessed.

**Key Questions for Applicants to Consider**

Given the need to identify individuals at high risk of long term nursing
facility placement, to be most effective, applicants would likely need
to carefully consider the following questions:

-   What was the original intent and the development process for the
    proposed eligibility criteria?

-   How will the proposed eligibility criteria best meet the program's
    goal of reducing Medicaid utilization of nursing facility services?

-   How does the eligibility criteria and process compare to current
    practices for other programs (e.g., Medicaid nursing facility level
    of care)?

-   How do the proposed criteria incorporate: 1) functional status; 2)
    health status; 3) cognitive/emotional status; 4) informal support
    and caregiver burden; and 5) any other areas?

-   What are the procedures for periodic re-assessments to determine if
    beneficiaries continue to meet eligibility criteria?

-   What are the procedures for capturing assessment data in an
    electronic format?

-   Who will administer the screen/assessment and how will this be
    coordinated with existing efforts?

[^1]: Spector, Reschovsky & Cohen (1996). Appropriate placement of
    nursing home residents in lower levels of care. *The Milbank
    Quarterly*, 74:139-160.

[^2]: Weissert and Hedrick (1994). Lessons learned from research on
    effects of community based long-term care. *Journal of the American
    Geriatrics Society*, 42: 348-353; Grabowski (2006). The cost
    effectiveness of noninstitutional long-term care services: review
    and synthesis of the most recent evidence. *Medical Care Research
    and Review*, 63(1): 3-28.

[^3]: Greene, Lovely, & Ondrich (1993). The cost effectiveness of
    community services in a frail elderly population. *The
    Gerontologist, 33*[:]{.underline} 177-189.

[^4]: Miller and Weissert (2000). Predicting elderly people's risk of
    nursing home placement, hospitalization, functional impairment and
    mortality: a comprehensive review and analysis. *Medical Care and
    Research Review*, 57(3): 259-297.

[^5]: Ashok J. Bharucha MD, Rajesh Pandav MBBS, MPH, Changyu Shen BS,
    Hiroko H. Dodge PhD, Mary Ganguli MD, MPH (2004) Predictors of
    Nursing Facility Admission: A 12-Year Epidemiological Study in the
    United States. *Journal of the* *American Geriatrics Society* 52
    (3), 434--439.
    <http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2004.52118.x?journalCode=jgs>

[^6]: Yael Harris PhD, MHS, James K Cooper MD (2006) Depressive Symptoms
    in Older People Predict Nursing Home Admission\
    *Journal of the American Geriatrics Society* 54 (4), 593--597.
    doi:10.1111/j.1532-5415.2006.00687.xYael Harris PhD, MHS, James K
    Cooper MD (2006) Depressive Symptoms in Older People Predict Nursing
    Home Admission *Journal of the American Geriatrics Society* 54 (4),
    593--597.

[^7]: [http://www.adrc-tae.org/documents/Assessment%20Instruments%20in%2012%20States.pdf](http://www.adrc-tae.org/documents/Assessment Instruments in 12 States.pdf)

[^8]: Wisconsin Department of Health and Family Services, Office of
    Strategic Finance, *Testing The Reliability And Validity Of The
    Wisconsin Long Term Care Functional Screen*,
    <http://dhfs.wisconsin.gov/LTCare/Waiver/b/1915bAttachmentAIatt3c1.pdf>

[^9]: Anita Slade, Jon Fear, and Alan Tennant (2006) Identifying
    patients at risk of nursing home admission: The Leeds Elderly
    Assessment Dependency Screening tool (LEADS) *BMC Health Serv Res*.
    2006; 6: 31
    <http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1513555>