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Home and Community Based Services Manual

4.10 Explanation of Level of Care Determination

Home and Community Based Services Manual


4.10 Explanation of Level of Care Determination

Revised - September 2024

Introduction

Individuals seeking Home and Community Based Services (HCBS) must meet nursing facility Level of Care (LOC). This measures the same eligibility criteria required for entry into a nursing facility as outlined in 19 CSR 30-81. LOC is determined during (re)assessments completed by Division of Senior and Disability Services (DSDS) staff or their designee.

Purpose

DSDS utilizes the InterRAI HC tool to conduct assessments. Based on the information gathered, algorithms within the electronic case record system determine the LOC score in individual categories. With an assessed LOC score of 18 points or higher, an individual is determined to be qualified for LOC and eligible for HCBS. If the individual does not meet LOC, they are determined to be ineligible and appropriate Adverse Action steps should be taken.

Categories

Cognition

  • Determine if the participant has an issue in one or more of the following areas:
    • Cognitive skills for daily decision making and ability to complete task in a sequence
    • Memory or recall ability (short-term, procedural, situational memory)
    • Disorganized thinking/awareness – mental function varies over the course of the day
    • Ability to understand others or to be understood
0 pts3 pts6 pts9 pts18 pts

No issues with cognition

AND

No issues with memory, mental function,
or ability to be understood/ understand
others

Displays difficulty making decisions
in new situations or occasionally
requires supervision in decision making
 

AND

Has issues with memory, mental function,
or ability to be understood/ understand others

Displays consistent unsafe/poor
decision making or requires
total supervision

AND

Has issues with memory mental
function, or ability to be
understood/ understand others

Rarely or never has the
capability to make decisions

OR

Displays consistent unsafe/poor
decision making or
requires total supervision

AND

Rarely or never
understood/able to understand others

Trigger:
Comatose state

Eating

  • Determine the amount of assistance the participant needs with eating and drinking. Includes intake of nourishment by other means (e.g. tube feeding or TPN).
  • Determine if the participant requires a physician ordered therapeutic diet.
0 pts3 pts6 pts9 pts18 pts

No assistance needed

AND

No physician ordered diet

Physician ordered therapeutic diet

OR

Set up, supervision, or limited assistance needed with eating

Moderate assistance needed with eating,
i.e. participant performs more than 50% of the task independently		Maximum assistance needed with eating,
i.e. participant requires caregiver to perform more than 50% for assistance		Trigger:
Total dependence on others

Behavioral

  • Determine if the participant:
    • Receives monitoring for a mental condition
    • Exhibits one of the following mood or behavior symptoms – wandering, physical abuse, socially inappropriate or disruptive behavior, inappropriate public sexual behavior or public disrobing; resists care
    • Exhibits one of the following psychiatric conditions –abnormal thoughts, delusions, hallucinations
0 pts3 pts6 pts9 pts18 pts

Stable mental condition

AND

No mood or behavior symptoms observed

AND

No reported psychiatric conditions

Stable mental condition monitored by a physician or licensed mental health professional at least monthly

OR

Behavior symptoms exhibited in past, but not currently present

OR

Psychiatric conditions exhibited in past, but not recently present

Unstable mental condition monitored by a physician or licensed mental health professional at least monthly

OR

Behavior symptoms are currently exhibited

OR

Psychiatric conditions are recently exhibited

Unstable mental health condition monitored by a physician or licensed mental health professional at least monthly 

AND

Behavior symptoms are currently exhibited

OR

Psychiatric conditions are currently exhibited

---

Toileting

  • Determine the amount of assistance the participant needs with toileting. Toileting includes using the toilet (bedpan, urinal, commode), changing incontinent episodes, managing catheters/ostomies, and adjusting clothing.
  • Determine the amount of assistance the participant needs with transferring on/off the toilet.
0 pts3 pts6 pts9 pts18 pts

No assistance needed

OR

Only set up or supervision needed

Limited or moderate assistance needed, i.e. participant performs more than 50% of task independentlyMaximum assistance needed, i.e. participant needs 2 or more helpers or more than 50% of caregiver weightbearing assistanceTotal dependence on others---

Bathing

Determine the amount of assistance the participant needs with bathing. Bathing includes taking a full body bath/shower and the transferring in and out of the bath/shower.

0 pts3 pts6 pts9 pts18 pts

No assistance needed

OR

Only set up or supervision needed

Limited or moderate assistance needed, i.e. participant performs more than 50% of task independently

Maximum assistance, i.e. participant needs 2 or more helpers or more than 50% of caregiver weightbearing assistance

OR

Total dependence on others

------

Treatments

  • Determine if the participant requires any of the following treatments:
    • Catheter/Ostomy care
    • Alternate modes of nutrition (tube feeding, TPN)
    • Suctioning
    • Ventilator/respirator
    • Wound care (skin must be broken)
0 pts3 pts6 pts9 pts18 pts
None of the above treatments needed---One or more of the above treatments are needed------

Dressing and Grooming

  • Determine the amount of assistance the participant needs with:
    • Personal Hygiene
    • Dressing Upper Body
    • Dressing Lower Body
0 pts3 pts6 pts9 pts18 pts

No assistance needed

OR

Only set up or supervision needed

Limited or moderate assistance needed, i.e. participant performs more than 50% of task independently

Maximum assistance, i.e. participant needs 2 or more helpers or more than 50% of caregiver weightbearing assistance

OR

Total dependence on others

------

Rehabilitation

  • Determine if the participant has the following medically ordered therapeutic services:
    • Physical therapy
    • Occupational therapy
    • Speech-language pathology and audiology services
    • Cardiac rehabilitation
0 pts3 pts6 pts9 pts18 pts
None of the above therapies orderedAny of the above therapies ordered, 1 time per weekAny of the above therapies ordered 2- 3 times per weekAny of the above therapies ordered 4 or more times per week---

Meal Prep

  • Determine the amount of assistance the participant needs to prepare a meal. This includes planning, assembling ingredients, cooking, and setting out the food and utensils
0 pts3 pts6 pts9 pts18 pts

No assistance needed

OR

Only set up or supervision needed

Limited or moderate assistance needed, i.e. participant performs more than 50% of task

Maximum assistance, i.e. caregiver performs more than 50% of task

OR

Total dependence on others

------

Medication Management

  • Determine the amount of assistance the participant needs to safely manage their medications. Assistance may be needed due to a physical or mental disability.
0 pts3 pts6 pts9 pts18 pts
No assistance needed

Setup help needed

OR

Supervision needed

OR

Limited or moderate assistance needed, i.e. participant performs more than 50% of task

Maximum assistance needed, i.e. caregiver performs more than 50% of task

OR

Total dependence on others

------

Mobility

  • Determine the participant’s primary mode of locomotion
  • Determine the amount of assistance the participant needs
    • Locomotion – how moves in the home, between locations on the same floor (walking or wheeling). If wheeling, how much assistance is needed once in the chair?
    • Bed Mobility – transition from lying to sitting, turning, etc. while in bed
0 pts3 pts6 pts9 pts18 pts

No assistance needed

OR

Only set up or supervision need

Limited or moderate assistance needed, i.e. participant performs more than 50% of task independently

Maximum assistance needed for locomotion or bed mobility, i.e. participant needs 2 or more helpers or more than 50% of caregiver weight-bearing assistance

OR

Total dependence for bed mobility

---

Trigger:
Participant is bedbound

OR

Total dependence on others for locomotion

Safety

  • Preliminary safety LOC score
    • Determine if the individual exhibits any of the following risk factors:
    • Vision Impairment
    • Falling
    • Balance – moving to standing position, turning to face the opposite direction, dizziness, or unsteady gait.
  • After determination of preliminary score, history of institutionalization in the last 5 years and age will be considered to determine final score.
    • Institutionalization – long term care facility, RCF/ALF, mental health residence, psychiatric hospital, settings for persons with intellectual disabilities
    • Age – 75 years and over
0 pts3 pts6 pts9 pts18 pts

No difficulty or some difficulty with vision

AND

No falls in last 90 days

AND

No recent problems with balance

Severe difficulty with vision (sees only lights and shapes)

OR

Has fallen in last 90 days

OR

Has current problems with balance

OR

Preliminary score of 0

AND

Age or Institutionalization

No vision

OR

Has fallen in last 90 days

AND

Has current problems with balance

OR

Preliminary score of 0

AND

Age

AND

Institutionalization

OR

Preliminary score of 3

AND

Age or Institutionalization

Preliminary score of 6
 

AND

Institutionalization

Trigger:
Preliminary score of 6

AND

Age Preliminary score of 3
 

AND

Age

AND

Institutionalization

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