Scoring Methodology For PCS Eligibility Determination and Service Level Authorization

1. Scoring Methodology For PCS Eligibility Determination and Service Level Authorization Prepared For: PCS Stakeholder Meeting November 21, 2013

2. Overview

3. Scoring Design • Two Purposes • Beneficiary eligibility determination • If beneficiary is eligible, determination of authorized hours/units • Scoring Is Based On Consolidated PCS Assessment • Must be completed, uploaded and validated first • Individual assessors do not determine eligibility or the authorized hours • Scoring is computerized – performed by QiRePort • Current Scoring Methodology • Rule-based reflecting current PCS clinical coverage policy • Planned Modification to Scoring • Implement provisions of Session Law 2013-306 for expanded hours determination • Modification contingent upon approval of the state plan amendment

4. Determining Basic PCS Eligibility

5. Eligibility Determination Considerations • Based on Beneficiary’s Qualifying Activities of Daily Living (ADLs) • Bathing/personal hygiene • Dressing • Mobility • Toileting • Eating • Determination of Qualifying ADLs • Criterion 1. Level of assistance need for an individual ADL • Requires at least limited hands-on assistance or greater for the ADL • Criterion 2. Frequency of assistance need • Requires a PCS weekly need frequency of “1” day or greater for at least one ADL task need of an ADL where there is need for at least limited hands-on assistance. Let’s look at the assessment data used to apply these two criterion:

6. Criterion 1. Level of ADL Assistance Need • Self-Performance Rating Options: • Totally able, no assistance required • Needs verbal cueing/supervision only • Can do with limited hands-on assistance • Can do with extensive hands-on assistance • Cannot do at all Assessor enters self-performance ADL assessment rating here in each ADL assessment section. • Minimum Eligibility Requirement - Either: • Three or more ADLs requiring at least limited hands-on assistance or greater – OR -- • At least one ADL requiring extensive or greater hands-on assistance and one other ADL requiring at least limited hands-on assistance or greater.

7. Criterion 2. Frequency of Need Applies only to ADLs where the beneficiary’s self-management capacity rating is limited hands-on assistance or greater The PCS need frequency is at least 1day/week. At least one ADL task need is checked as required. Looking across all the required tasks, also determine what the highest PCS need frequency (days/week) is for each qualifying ADL and also across all qualifying ADLs.

8. Calculation of Authorized Hours For Qualifying Beneficiaries

9. Calculation Of Authorized Hours - Current • Primary Assessment Information Used in Calculate Service Levels • ADLs requiring at least limited assistance (Sections I – M) • Frequency of PCS need for qualifying ADLs (Sections I -- M) • Medications assistance needs (Section E) • Special assistance task needs (Section N) • Delegated medical monitoring tasks (Section N) • Exacerbating conditions (Section O) • Environmental conditions and circumstances affecting beneficiary safety and ADL self-performance/assistance time (Section P) • Six Step Process For Determining PCS Hours • Performed by QiRePort • Performed only after the assessment is uploaded and validated

10. Step 1. Determine Base Minutes Per Day Based on assessed level of self-management capacity for each ADL * Base minutes per day.

11. Step 2. Determine Medication Assistance Need • Determine Daily Medication Assistance Minutes Based On Assigned Level of Medication Assistance Need • Assessment Information Used To Assign Meds. Assistance Level • Assessor’s assessment of beneficiary’s ability to self-manage medications • Number of medications – to determine polypharmacy • Whether medications are scheduled (routine) or PRN • Complex administration – 1 or more meds that are complex in administration

12. Step 3. Calculate Weekly Minutes • For Each ADL, Convert Daily Minutes Into Weekly Base Minutes • Daily minutes established in Step 1 x the PCS need frequency (use maximum need frequency among required ADL tasks) • Daily minutes are determined in step 1. For ACH assessments only, meal preparation tasks are not considered when assigning minutes for the eating ADL. Determine if the average daily minutes is 60 or greater for the number of days PCS is needed. If not, increase to 60 daily minutes and then multiply by the maximum weekly need frequency . • Add Medications Weekly Minutes (as appropriate)

13. Step 4. Compute Special Needs Extra Time • Determine Extent Of Special Needs/Tasks in Four Areas: • # of special assistance tasks (Tasks 1-10) – account for PCS need frequency as documented in the ADL profiling • # of delegated medical monitoring tasks – determine if the monitoring task(s) require more than 5 minutes of assistance each PCS visit? (Count as 1) • # of exacerbating conditions -- count those that affect qualifying ADLs • # of environmental conditions – count those that affect qualifying ADLs • Determine What Multiplier To Use For Additional Minutes • Add the Additional Minutes To The Weekly Minutes

14. Step 5. Calculate Monthly Hours • Multiply The Total Weekly Minutes by 4.35 • Convert To Hours and Units

15. Step 6. Limit Hours As Required By Policy • QiRePort Calculates PCS Hours Based On the Scoring Methodology • Scoring can result in more than 80 hours • Authorized Hours Are Currently Limited By Clinical Coverage Policy (3L) • Allow up to 80 hours/mo. for adults • Allow up to 60 hours/mo. for beneficiaries under age 21(unless the DMA ESPDT review overrides the scoring result)