Appropriate Health and Functional Criteria for Access to Long-Term Services and Supports

Background

People of all ages may need long-term services and supports (LTSS) because they have limited ability to perform a variety of physical or cognitive activities.

Difficulties in performing self-care, and thus the need for LTSS, are typically measured using two scales. The first is the activity of daily living scale, which includes eating, transferring (e.g., from bed to chair), toileting, dressing, bathing, and continence. The second is the instrumental activity of daily living scale, which includes ability to manage medications and personal finances, do housework and laundry, shop, and use a telephone and public transportation.

In the Medicaid program, most states refer to health and functional criteria as “level-of-care” criteria, because individuals must need a specific level of care to receive services. People who apply for home- and community-based services through a waiver program must meet the same eligibility criteria as those who apply for nursing facility care. Medicaid criteria vary among states and among LTSS programs within a state. People who would be eligible for services in one program may not be eligible for another program within the state or for that same program in another state.

In many states, the criteria for determining eligibility for LTSS have a medical bias, such that medical and nursing needs are given more weight than functional impairments. But existing means of measuring cognitive and mental impairments have limited effectiveness for determining whether a person can function independently and for identifying individuals who need services. The need for supervision, for example, is critical in determining cognitive impairment and is an important eligibility criterion, and yet adequate ways to measure the need for supervision do not exist. This area needs further research.

There is a growing preference among people with disabilities to enhance self-empowerment and self-determination. They assume informed risks and make their own decisions about their care. Policymakers should recognize that the majority of services and supports that people with disabilities require are nonmedical in nature.

Appropriate Health and Functional Criteria for Access to Long-Term Services and Supports: Policy

Accuracy of eligibility criteria

In this policy: FederalState

Federal and state long-term services and supports (LTSS) programs should have eligibility criteria that appropriately measure the need for LTSS.

Measurements for eligibility criteria must accurately assess people with physical, cognitive, and mental impairments and chronic illnesses.

People should be eligible for LTSS on the basis of functional needs.

People with physical impairments should become eligible for LTSS benefits if they have difficulty performing at least two of the five basic activities of daily livingADLs include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. .

Cognitive, mental and physical impairment

In this policy: FederalState

Programs should include appropriate functional criteria, such as measures of cognitive and other mental impairments, as well as physical impairments.

State assessment tools

In this policy: FederalLocalState

In the absence of federal policy, states should develop uniform assessment instruments for use in all state LTSS programs, including Medicaid, and include an assessment of family caregiver needs as appropriate.

Assessments should be valid and reliable, and core items should be uniform across populations.