Medicaid Long-Term Care: State Use of Assessment Instruments in Care Planning
Published: 1996-04-02T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Pursuant to a congressional request, GAO reviewed how publicly funded programs assess the need for home and community-based long-term care services for the poor disabled elderly, focusing on the: (1) comprehensiveness of the assessment instruments; (2) uniformity of their administration; and (3) uniformity of training for staff who conduct the assessments.
section_title: What GAO Found
paragraphs: GAO found that: (1) all 49 states reviewed use an assessment instrument to determine the long-term care needs of the poor disabled elderly and some also use them for other eligibility determinations; (2) 48 of the programs provide information to their clients about services not covered and most give referrals and assistance to obtain those services; (3) all of the assessment instruments covered physical and mental health and functional abilities of the disabled elderly, but inclusion of their social resources, economic resources, and physical environment ranged from 69 percent to 84 percent; (4) dependence on assistance with daily living activities was the only specific topic included in all instruments; (5) most assessments use face-to-face interviews, but only a minority of them specify the wording of questions; (6) most programs have experience and professional credential requirements for their assessors, but most programs do not require standardized training; and (7) experts believe that assessment instruments could be improved by including more topics, standardizing the wording and order of questions, and training assessors in use of the instruments.

section_title: Letter
paragraphs: At your request, we examined how publicly funded programs assess the need for home and community-based long-term care services for elderly persons with disabilities. This care is provided to persons who live at home and who, because of a chronic condition or illness, are unable to take care of themselves. Services include a broad range of support, from skilled nursing to assistance with such basic activities of daily living as bathing, toileting, and dressing; help with the instrumental activities of shopping, meal preparation, housekeeping, and laundry; and the provision of home-delivered meals.
Under the Medicaid program, states can obtain waivers to provide home and community-based services to low-income elderly persons if they would otherwise require institutional care paid by Medicaid. Forty-nine states had waivers at the time of our study.
States receiving waivers are responsible for planning the care of individual clients. The development of a care plan appropriate to the specific needs of a client is facilitated by use of an assessment instrument. A well-designed assessment instrument aids in the identification of all appropriate needs so that, if possible, they can be met. An instrument with relatively comprehensive content increases the likelihood that important aspects of the client’s situation will not be overlooked in care planning.
Standardized administration of the assessment instrument increases the likelihood that the needs of all clients will be determined in the same way. It is important to note that in determining the care plan, information obtained from the assessment instrument is usually used in conjunction with information from other sources and clinical judgment.
To help you better understand the role of assessment in planning home and community-based care, we gathered information on the (1) comprehensiveness of assessment instruments, (2) uniformity of their administration, and (3) training for staff who conduct the assessments.
To gather this information, we performed five types of activities. First, we reviewed and summarized the literature on assessment instruments and program documentation. Second, we interviewed federal officials and experts in medicine, nursing, and social work. Third, we conducted site visits to state officials associated with several Medicaid waiver programs. Fourth, we developed and pretested a questionnaire and then used it to survey the 49 state Medicaid waiver programs providing home and community-based services to the elderly. Finally, we obtained and analyzed the content of the assessment instruments used by these programs.
subsections: section_title: Background
paragraphs: Geriatric assessment, defined as the skillful gathering of information about an elderly person’s health, needs, and resources, is a potentially useful component of any program for frail elderly clients needing home and community-based long-term care. Such assessment is especially relevant to multiservice programs that pay for a wide variety of services, such as the Medicaid waiver programs found in 49 states.
These programs are authorized by the Social Security Act, which allows for the waiver of certain Medicaid statutory requirements to enable states to cover home and community-based services as an alternative to client institutionalization. Such waivers, however, need not be statewide and can specifically target selected groups of individuals (for example, the elderly). The home and community-based services must be furnished in accordance with a plan of care aproved by the State Medicaid Agency. The instruments used to determine the level of care, the qualifications of those using these instruments, and the processes involved in assessment are systematically reviewed and must be approved by the administrative staff of the Medicaid program. These controls on the tools, personnel, and processes involved in establishing program eligibility are likely to benefit the care planning process. However, relatively little is known about the assessments used by waiver programs to develop care plans for the elderly, how they are used, what they cover, how they are administered, and the qualifications of those who administer them.
The elderly clients who apply for home and community-based care usually undergo cycles of assessment. Depending upon each client’s assessment, the program determines the services that should be delivered to the client over a period of time, utilizing a clinical decision-making process that results in a plan of care. Care planning processes vary among and within the states, and there is no single agreed-upon way to translate the results of assessment into a care plan. However, without good care planning, even the best assessment may not be helpful in achieving the most appropriate services for clients.
Starting from this plan, program personnel (or personnel contracted by the program) directly authorize appropriate services and, when services are not available through the waiver program, may provide information to the client on how those services might be obtained. As the client’s needs for services change or a specified period of time passes, program personnel reassess the needs and adjust the care plan accordingly.
Each state Medicaid waiver program for the elderly has the freedom to develop and adopt its own assessment instrument with no specific federal guidelines for content or process of administration. Most of the information gathered by these instruments falls under one of six broad domains, which are recommended by experts in geriatric assessment and found in most of the published instruments developed to assess the frail elderly. They are: (1) physical health, (2) mental health, (3) functioning (problems with daily activities), (4) social resources, (5) economic resources, and (6) physical environment. To the extent that these domains are included, the instrument can be thought of as comprehensive.
The completion of the assessment instrument is often based on one or more interviews between the client and the assessor. Information from other sources, such as medical records or interviews with family members, may also be included. Regardless of its formal elements, the entire assessment process must be skillfully coordinated by the assessor or assessors involved. This is necessary to maximize the useful information obtained within the limits set by the capacities of the elderly clients being served and their understandable preference to “tell their stories” as they choose.
section_title: Scope and Methodology
paragraphs: We conducted a literature review on assessment instruments; interviewed experts in geriatric assessment and state and local officials; and visited several state Medicaid programs (California, Oregon, and Florida). From the exhaustive literature review and interviews with the nationally recognized experts identified through the literature, we learned about good practices in geriatric assessment. (See appendix I for a list of experts.) From officials and visits to state programs, we learned about the goals, procedures, and difficulties of assessment in the field and gathered information to help inform our data collection. We then conducted a survey of all 50 states and the District of Columbia about their assessment instruments for the Medicaid waiver programs that provide the elderly with multiple services (in some places referred to as elderly and disabled waiver programs).
We asked the head of each waiver program (or the most appropriate staff) to complete a questionnaire and send us a copy of their assessment instruments used to develop the care plans of elderly clients. The questionnaire requested two kinds of information: (1) general information about the program and (2) detailed information about the assessment instrument or instruments used to develop the clients’ care plans, the assessment and care planning processes, and training and educational requirements of the assessors.
After an extensive developmental process, we pretested the questionnaire in two states and incorporated necessary changes suggested by state officials. We then mailed the questionnaire to all states and gathered information between July 1994 and January 1995. The District of Columbia and Pennsylvania indicated that they did not have Medicaid waiver programs for the elderly and, therefore, were excluded from our sample. The 49 states with Medicaid waiver programs all responded to our questionnaire.
We conducted our work in accordance with generally accepted government auditing standards.
section_title: Principal Findings
subsections: section_title: All Instruments Assess Client’s Health, and Most Assess Other Domains
subsections: section_title: Programs Use Assessment for Care Planning
paragraphs: All 49 states reported to us that they use an assessment instrument to determine the care plan for each client, including the identification of needed services available both through the waiver program and outside the program. In addition, 43 states use the assessment to determine an elderly person’s functional eligibility for the waiver program (level of care), and 31 states use part of the instrument as a preadmission screen for possible nursing home care.
The programs rely upon several types of information to develop care plans, including client’s preference, clinical impression, assessment scores, caregiver’s preference, budgetary caps, and medical records. Most programs use the assessor’s clinical impression, based on the assessment interview, and any scores or ratings generated by the assessment process most or all of the time. (See table 1.)
Forty-eight of the programs told us that they “almost always” or “most of the time” provide clients with information about providers from whom they can get services not offered by the waiver program; 45 states provide them with referrals to such services; 35 provide them with assistance in obtaining these services; and 34 of the programs follow up clients to verify that the nonwaiver services have been obtained. It should be noted that some of these nonwaiver services may also be Medicaid-funded, such as home health care provided by Medicaid.
section_title: All Instruments Cover the Health Domains
paragraphs: We found that although all instruments gather some information on the broad domains of physical health, mental health, and functioning, not all of them cover the other three domains of a comprehensive assessment of an elderly person (84 percent cover social resources, 69 percent cover economic resources, and 80 percent cover physical environment). Within each of the six domains, certain specific topics are covered by a number of instruments. We found that all state instruments consistently gather information on assistance with activities of daily living (for example, bathing, toileting, and dressing). Table 2 shows the relative frequency of occurrence of any coverage whatsoever for each domain and for each topic found in 10 percent or more of the instruments.
This list of topics does not represent an accepted standard. Different topics within a domain may yield similar or equivalent information. There may be other topics, not listed, that can also contribute to comprehensive assessment, and for some clients, skillful probing by assessors may be needed to obtain important contextual information not listed on any assessment form.
It should also be acknowledged that, in particular instances, selected topics missing from instruments do not imply that states are not informed about these topics. Such information may be available from other sources. Also, the nature of the program or characteristics of the population may make certain information less relevant. For example, the financial eligibility rules of some states may obviate the need to ask about all the topics in the economic resources domain. Such repetition of topics would make the assessment unreasonably burdensome for the clients as well as for those programs with relatively limited resources (staff, time, or money). Less comprehensive instruments should be evaluated in the context of their particular programs to determine if sufficient information is collected about the client’s physical and mental health, functional status, social and economic supports, and home environment to develop an appropriate care plan.
section_title: Administration Is Not Uniform for Many Instruments
paragraphs: We found that although most assessments are conducted as face-to-face interviews, only 35 percent of the instruments specify the wording of any of the interview questions that assessors ask the clients. Further, when the wording is not specified, it is often unclear in what order different elements of information are to be gathered. Instruments with specified wording, however, are usually designed to gather information in a particular order. This lack of uniformity in instrument administration may lead to unnecessary variation in how different clients perceive, and therefore respond to, requests for “the same information.”
For example, some replies to questions about depression may differ depending on whether they are asked before or after questions about physical health. Also, questions about activities of daily living, such as bathing, may evoke different replies depending on whether the client is asked if he or she “can bathe” or “does bathe.” Although there may be no universally agreed-upon “correct” wording for such items, once such a wording is decided upon, there may be benefits to employing it consistently within a given program.
section_title: Many Programs Do Not Require Assessors to Be Trained in Use of the Instrument
paragraphs: We found that 53 percent of the programs using a single assessor mention a years-of-experience requirement, and 57 percent of the programs using a team of two assessors mention this requirement for their lead assessor (for the second assessor, it is 50 percent). Moreover, most states require assessors to possess specific professional credentials. Thus, programs attempt in various ways, such as by the adoption of hiring (or contracting) and training standards, to ensure that assessors perform their job competently. However, no particular background or training requirements can guarantee optimal assessment for all clients.
We found that only 31 percent of the programs require training the assessor in how to use the instrument, although such training may be obtained without a requirement. Assessors who are not similarly trained in the use of the instrument, regardless of their credentials or other training, may not respond uniformly to common occurrences, such as a client’s fatigue or a request to clarify a question. Assessors may administer the same instrument differently, even with standardized order and wording of the questions, based on differences in clinical training or experience in other situations.
section_title: Experts’ Suggestions for Improving Assessments
paragraphs: In light of the observed variability in waiver program assessments—with respect to instrument content, instrument standardization, and assessor requirements—the experts we consulted and the literature in gerontology make the following suggestions for improvement:
First, a number of topics, such as those listed in table 2, have proved useful in assessing the elderly. Programs that do not cover a wide variety of these can increase the comprehensiveness of their assessments by including more of these topics.
Second, standardizing the wording and order of questions generally increases the comparability of the clients’ replies.
Finally, another important element in achieving uniformity of instrument administration is assessor training in use of the instrument.
section_title: Conclusions
paragraphs: We have drawn three conclusions about the assessment instruments and their administration. First, we found that although all states use assessment instruments to develop a care plan, there is variation in their level of comprehensiveness.
Second, we found that although most assessments are conducted as face-to-face interviews, many state instruments do not have standardized wording.
Third, we found that although training in the administration of the instrument may be important in achieving uniformity of administration, many states do not require such training.
section_title: Agency Comments
paragraphs: The Health Care Financing Administrator provided written comments on a draft of this report. (See appendix II.) The agency did not disagree with our findings, but listed some circumstances that help clarify variations across states. Specifically, they noted that waiver programs are frequently administered by different state agencies, which not only bring different perspectives to the assessments, but also use them for a variety of different purposes and may use more than one instrument. Through our state survey, we also found that some states use multiple assessment instruments, and some use them for multiple purposes.
In oral comments on our draft report, responsible agency officials made some technical comments. We have incorporated these into the text where appropriate.
As discussed with your office, we will be sending copies of this report to the Subcommittee Chairman, to other interested congressional committees and agencies, and to the Department of Health and Human Services and the Health Care Financing Administration. We will also send copies to others who request them.
If you or your staff have any questions about this report, please call me or Sushil K. Sharma, Assistant Director, at (202) 512-3092. The major contributors to this report are listed in appendix III.
section_title: Experts Consulted
paragraphs: Kathleen C. Buckwalter, Ph.D., University of Iowa Robert Butler, M.D., Mount Sinai Medical Center, N.Y.
section_title: Agency Comments
section_title: Major Contributors to This Report
subsections: section_title: Program Evaluation and Methodology Division
paragraphs: Donald M. Keller, Project Manager Venkareddy Chennareddy, Referencer We wish to acknowledge the assistance of R.E. Canjar in collecting and organizing the data and Richard C. Weston in ensuring data quality.
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