Occasional LTC Policy Paper Series
Duke Long Term Care Resources Program Paper No.6
Pre-Assessment Screening: An Essential
Building Block in LTC Information Systems
George L. Maddox, Ph.D., and Stuart Bratesman, Jr., MPP
Overview
The North Carolina Department of Health and Human Services (DHHS)
should establish pre-assessment screening as a standard practice
across programs that provide services for the elderly and for
disabled adults. Pre-assessment screening is an economical way
to identify those for whom more detailed information is required
in order to match need and services. If DHHS is to ensure that
adequate screening procedures are widely adapted and properly
used, then it must provide training opportunities statewide.
Meanwhile, case and program managers need not and should not
wait for DHHS to establish a statewide policy on pre-assessment
screening.
The Duke Services Outcome Screen (SOS) provides an available, generic, and
economical automated technology for pre-assessment screening of frail elderly and
disabled persons. Duke SOS has been designed for appropriate use over a wide variety
of long term care settings. Duke SOS is already used, in either its paper or automated
form, by agencies and organizations in over half the counties in North Carolina. Duke
SOS screening interviews are typically completed by phone in fifteen-to-twenty minutes.
Duke SOS can be integrated with state-of-the-art information and referral (I&R)
technology and it provides a basic introduction to screening, an introduction that can
prepare and ease the adoption of other screening technologies in the future.
Why Screen?
Screening is quick, economical and has multiple uses in
LTC. |
Care managers and service providers for the
elderly and disabled screen potential clients to determine their
appropriateness and likelihood of eligibility for services and
follow-up. Screening helps service professionals to quickly,
economically, and reliably:
- Decide whether it is worthwhile to pursue a lengthy and more costly
full-assessment
- Make a well-informed referral choices for other services and agencies
- Identify clients and applicants with urgent unmet needs
The Advantages of a Client Strategy that Includes Screening
| Screening benefits both clients and
agencies. |
While screening may appear at first to be
an extra step that adds more work, a client strategy that includes
screening actually allows most agencies to operate more
efficiently and to provide better service to the people they
help.
| When screening reduces waiting lists
- eligible clients can be served sooner. |
Many programs that serve the frail elderly
have lengthy enrollment procedures and long waiting lists. Screening
reduces waiting lists and means shorter waiting periods for
older and disabled people waiting to enroll. The early and reliable
identification of referred applicants who are clearly
ineligible or clearly inappropriate for an agency's services
typically results in a significant reduction in the number of
applicants who require time-consuming full assessments. The
shortening of the waiting list and the reduction in the number
of full assessments both mean that those applicants who are
more appropriate and more likely to be approved are assessed
earlier and enroll in services sooner.
| Screening saves time and money. |
For programs and services that require a
lengthy full assessment as a pre-condition to enrollment, the
reduction in the number of full assessments performed
on inappropriate and ineligible applicants frees up valuable
staff time and agency resources to be redirected to other client
needs. These savings can be illustrated by example.
North Carolina's Community Alternatives Program for
Disabled Adults (CAP/DA), the state's Medicaid waiver
program for home and community based service alternatives
to nursing home placement, currently estimates that the cost
of a full assessment is about $205. We'll be optimistic and
assume the average cost of full assessment to be $150.
Assume that an agency uses a case manager to perform a
20-minute screen for all serious requests for CAP/DA
enrollment. While pre-assessment screening is not a
Medicaid reimbursable expense, other case manager
activities are currently reimbursed at $41 per hour. Thus, it
would cost close to $14 to conduct a screen that takes one-
third of an hour to complete.
From 1995-to-1997, the twelve CAP/DA agencies that
participated in the Aging at Home II program (managed by
Duke LTC) employed a strategy of screening prior to
assessment. Of the 1,900 applicant referrals to these
programs over 24 months, 1,617 (85%) were screened, and
of those screened, 559 (35%) were deemed appropriate for
full assessment.
Had all 1,617 applicants been assessed at just $150 each, it
would have cost the Medicaid waiver program $242,550.
However, screening all 1,617 at $14 each and assessing 559
applicants at $150 results in a net savings of $136,600 or
56% of the cost of performing full assessments without
screening.
| A structured screening interview
will often uncover important client aspects otherwise
missed. |
Even for those programs, such as Home and
Community Care Block Grant Services, that do not require lengthy
and costly full assessments prior to enrollment, a well-designed
multidimensional screening tool can give a clearer and more
comprehensive picture of the applicant's needs and strengths.
A structured screening interview that covers all the bases will
often uncover important aspects of a client's functional capacity
or environment that would have been otherwise missed in a free-form
conversation. Well-designed screening tools also systematically
categorize and summarize client responses for easier analysis
and comprehension.
| Screening provides early warning
for urgent situations. |
The screening strategy also offers many other
benefits to clients and agencies alike. Screening can uncover
and detect applicants with urgent situations that demand a quick
response. This could mean early priority enrollment in
those programs that allow it, or a quick referral to another
program or agency that could appropriately address the urgent
situation sooner.
| Screening before assessment makes
for better quality assessments. |
When it comes time to perform a full assessment,
experienced care managers find it easier and faster to complete
a more thorough assessment if the applicant has been previously
screened. The information and insights gained from screening
allow assessors to prepare in advance, and to focus detailed
attention on the issues that have the greatest bearing on the
client's status, frailties, and supports.
Early screening alerts ineligible
clients to look sooner to find appropriate alternatives.
Screening informs more appropriate referrals. |
The screening strategy also benefits those
clients who are deemed inappropriate for full assessment and
enrollment. The early discovery of ineligibility and quick feedback
to clients allow ineligible applicants and their families to
shift their focus to other services and programs at a much earlier
date, instead of pinning false hopes on a full assessment that
will eventually turn them down. In addition, the multi-
dimensional portrait of the applicant's functional status, environment
and supports revealed by the screen can help care managers and
information and referral specialists make much better informed
decisions about referrals to more appropriate programs and services.
Screening data can be analyzed for better evidence-based program planning.
Finally, the rich, multi-dimensional screening data collected across
many applicants can be analyzed to identify the variety and
dimensions of unmet service needs in the community, and to compare
enrolled clients and all applicants to other measured populations of
older and disabled adults, such as those described in the National
Long Term Care Survey.
| A care manager may benefit from a
multidimensional screening procedure . . . without having
to mobilize a full professional assessment. |
Asking the Right Questions
In the development of any information system intended to help
in case management for older adults and the disabled, asking
the right questions is essential. This point was well made almost
two decades ago by Robert and Rosalie Kane (1981) in their respected
practical guide for screening and assessing older adults. Wanting
to know whether an individual warrants a detailed and expensive
full professional assessment is not the same as actually providing
such an assessment. A care manager may benefit from a multidimensional
screening procedure that provides a reliable profile of functioning,
recent medical experience, social support, housing and income
without having to mobilize a full professional assessment. Or
a program manager may want the profile of persons being served
to monitor fulfillment of program mission.
| The Duke OARS Methodology became
the international Gold Standard for geriatric screening
. . . for many years. |
The practical advantage of a reliable, economical
pre-assessment screening procedure was noted in the development
of the Duke Older Americans Resources and Services (OARS) screening
methodology (Fillenbaum, 1988; Maddox, 1992). The Duke OARS
profiles of social support, economic adequacy, mental
health, physical health, and functional capacity were based
on information economically produced for a screening instrument
reliably administered by the equivalent of a high school educated
person with eight hours of training. Although the OARS Methodology
became the Gold Standard for geriatric screening among care
managers and program planners internationally for many years,
the 45 minutes required to administer it was considered to be
too long. Duke SOS, to be described below, was the response
in the 1990's for the request for a briefer Duke OARS.
Essential Distinctions Between Screening
and Assessment in Aging Service Programs
Exhibit 1 summarizes the basic distinctions between screening and assessment:
|
EXHIBIT 1
|
|
Screening
|
Assessment
|
| Technical training required |
Professional training required |
| Brief (15-30 minutes) |
Lengthy (45-60+ minutes) |
| Economical ($12-$20) |
Expensive ($100-$200) |
| Easy to summarize/profile |
Complex to summarize/profile |
| Easy to automate |
Expensive to automate |
| Can be administered by telephone |
Cannot be administered by telephone |
The Hallmarks of a Good Screening Instrument
The characteristics of an effective screening instrument include:
- Multidimensionality. (e.g. client identification, functional status,
client perception of need, cognitive and emotional status, health
indicators and health care utilization, social support, housing
and income adequacy);
- Standard, reliable comparable measures of self-care capacity
(ADL's), managing one's environment (IADL's), and social
support;
- Indicators of cognitive and emotional functioning;
- Indicators of social support in care giving;
- Indicators of income and housing adequacy;
- Established procedures for training in use of the instrument;
- Evidence of reliability and validity of measurement;
- Ease in computerization of the instrument and developing
summary profiles of clients useful to care managers and service
program managing;
- Ease in comparability of findings with those of available state
regional and national data sets; and
- Economy in training and use of the instrument.
Managing the Practical Politics of Professional and Agency
Acceptance
| Professionals have to be convinced
that screening is not intended to be substituted for the
informed clinical judgments. |
The availability of a reliable, valid screening
instrument does not assure its acceptance. The experience of
developing the Duke OARS in the early 1970's made it very clear
that professional and agency leadership in aging have strong
views about the use of standardized screening instruments. Professionals
have to be convinced that screening is not intended to
be substituted for the informed clinical judgments. Program
managers have to be convinced that economical, useful information
for program planning and evaluation can be generated by screening.
Moreover, even if there is sympathy for screening, choices have
to be made among available instruments.
A variety of screening instruments are available to be evaluated
in terms of their reliability and validity. Information about
experience of screening instruments in terms of their teachability,
their compatibility with larger information systems, their economy,
and their acceptance by professionals and program managers in
aging are scarce.
| Well over 100 agencies in more than
half of North Carolina's counties have been trained in
the use of Duke SOS. |
However, over the past decade, a large number
of professionals and program managers have been introduced to
Duke SOS and have been trained in the use of this screening
instrument. Voluntary training sessions have been well-attended
in a number of statewide meetings, and at regional sites across
the state. Well over one hundred agencies in over half
the counties in North Carolina have been exposed to the theory
and practice of pre-assessment screening through these Duke
SOS training sessions, and more than seventy agencies have chosen
the computerized automated version of the instrument.
| Choosing a screen wisely: Is it reliable
and valid and does it have wide acceptance in the field? |
The wise choice of a specific professional
instrument lingers, therefore, on evidence indicating that the
chosen instrument displays the hallmark characteristics of a
good screening tool, plus evidence of acceptance in the field
by professional and program managers and leaders. In our experience,
such acceptance is earned - and typically earned slowly.
| To date, state guidance has been
minimal. |
Next Step: Helping North Carolina Communities
and Counties Make Choices About Screening
Across the state, interest in the development of information
systems for aging services has intensified in recent years.
Many communities have taken specific steps to improve their
screening and assessment procedures, their I&R capacity and
their management information systems. To date, state guidance
of these developments has been minimal and fragmented across
Department of Health and Human Services Divisions. As a result,
the state is not realistically in a position to mandate particular
screening and assessment procedures for statewide adoption.
| State government should play a more
active role in coordinating local efforts, disseminating
information about screen, and offering training and professional
development. |
However, state government should have a role
in identifying developments across the state, to bring together
leaders in those communities that have developed policies regarding
information systems, and to ensure that evidence-based information
about the use of particular information strategies in the state
and nation are known. The state must go to the market place
of ideas in communities to build policies that will support
and coordinate existing developments of information systems.
DHHS should look first at its own information system and
ensure that it is state of the art in generating case and
program management information for professionals and
program leadership in North Carolina. This development will
increase the state's capacity to promote the technical
assistance and training to increase North Carolina's
capacity to develop and evaluate evidence-based policies to
serve older adults and their families effectively and efficiently.
Useful References
Fillenbaum, G. G. (1988) Multidimensional
Functional Assessment of Older Adults: The Duke Older Americans
Resources and Services Procedure. Hillsdale, N.J.: Erlbaum.
Kane, R. & Kane, R. (1981) Assessing the Elderly: A Practical
Guide to Measurement. Lexington, MA: Lexington Books.
Maddox, G.L. (1992) State-of-the-Art Research Summary: Teaching
Current Research Issues in Functional Assessment and Screening
in Gerontology. Washington: Association for Gerontology in Higher
Education.
Maddox, G.L., Bolda, E.L., & Breschel, E.F, (1991) Training
Manual for the Duke SOS Profile, Durham, N.C.: Duke Long Term
Care Resources Program.
Morris, J.N. Hanes, C. et al (1990). Designing The National
Resident Assessment Instrument for Nursing Homes. The Gerontologist,
30:3, 293-315.
O'Keefe, Janet, (1996) Determining the Need for Long-Term Care
Services: An Analysis of Health and Functional Eligibility Criteria
in Medicaid Home and Community Based Waiver Programs. Issue
Paper #9617, Washington: The Public Policy Institute, AARP.
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