Michigan interRAI HC-Based HCBS Assessment

Clinical Clarifications

Last updated 01/18/2010 1:10 PM

The following requests for clarification were submitted by staff at Waiver Agents throughout Michigan during the initial roll-out of a new iHC-based assessment instrument.

The requests for information were forwarded to:

· Pauline Belleville-Taylor, RN, Associate interRAI Fellow who works at the Institute for Training and Research at the Hebrew Rehabilitation Center for the Aged in Boston, Massachusetts

· Mary James, MA, Assistant Research Scientist at the Institute of Gerontology, University of Michigan, Ann Arbor, Michigan

· Elizabeth Gallagher, MPA, MI Choice Staff Specialist, Administrative Support and Contract Development Section, MDCH, Bureau of Medicaid Financial Management and Administrative Services

The original requests and available responses are listed below, with the most recent entries at the top:

24.) The question pertains to figuring out the number of physician visits for the iHC RN section I. The question from the case managers includes:  Is the physician number for unexpected visits or are routine scheduled visits included?  Do multiple visits in the same day count?  How is the number determined?	MARY: Per the interRAI HC manual, all physician visits, both scheduled and unexpected, are included.  If the person has two different appointments in the same day, then count as two different visits.  Note also that visits to nurse practitioners and physician assistants are included in this item.
23.) How should we code foot problems for a double amputee?	MARY: While there is not a specific item on the data collection form to indicate that a person has one or more missing body parts, this information can be included in Section I, Disease Diagnoses, under "current or more detailed diagnoses".  More detail can be added in the Comment section also. The correct coding for foot problems among amputees or people missing a foot/feet is “ 0 - no problems”.
22.) Question for Section P: (Functional Status) For the item ADL Self Performance- Bed Mobility, is the use of the word "bed" intended for any type of sleeping surface a participant uses (couch, lift chair, and/or other type of sleeping surface)?	MARY: That is the correct interpretation. The word “Bed” in this item applies to whatever sleeping surface is routinely used by the person.
21.) Question for section Q (Service Utilization): Are we supposed to complete this section when someone is being assessed in the nursing home? It seems like the questions pertain to home care not nursing home care.	MARY: While the language of these items is home care oriented, the intent is to collect this information for all individuals, regardless of setting, as it is needed to establish the person's current acuity level and plan for future assistance/supports. For persons in facility settings, it will be necessary to observe care, talk with the person/family/aides, and consult the person's record to get an accurate picture of care actually provided. Every person in a facility setting is likely to receive some amount of personal assistance and homemaker services; some individuals may also have social worker assistance during the look-back period. Code any therapies or special treatments provided to the person during the look-back period. Do not use "average" amounts of services time, as individuals vary greatly in facility settings as regards the extent of care received.
20.) It has come to my attention by case managers that the questions related to falls on the iHC seem to be confusing and difficult to work with. Specifically, Sec. J Health Conditions and Preventative Health Measures, Falls - gives options for length of time since last fall. Then it proceeds to ask Recent Falls with the advice to skip if... I noted that there is a distinction between history of falls and falls since last follow-up assessment. The time frame is 30 days and our reassessments are typically completed within 90 days (unless a sooner assessment is indicated). The coding options do not seem to pertain to the situation of the vast majority of our participants. Please help with clarification or further explanation of these two items. I fear that the information being gathered is less than accurate.	MARY: I will defer to Pauline if she has a different answer, but it seems to me that the recency of falls item is really not pertinent for MI programs, and will always be (properly) left blank, as indicated in the manual instructions, due to the length of time between assessments. It would have been easier if MI had simply dropped it, because assessors are instructed to “fill in every item". PAULINE: Here is the interRAI HC item Recent falls 0. No fall in last 30 days. 1. Yes, fall in last 30 days [blank] Not applicable (first assessment or more than 30 days since last assessment). On the Michigan item, there is no time frame under the Recent Falls Items, responses are “No” or “Yes”. Bottom Line = Falls triggers works; Multiple falls Or Single fall These are captured in the Michigan “Falls Item”. I agree with Mary about Recent Falls. This could have been dropped. As it is in the instrument, the “Not Applicable” option will be selected.
19.) Section Q - If a participant has a fistula for dialysis or a PIC line, can we consider that as dialysis and a sterile dressing change or IV therapy and a sterile dressing change, 2 separate treatments or is it considered the same?	PAULINE: Treatment or programs received or scheduled in last 3 days - the presence of a fistula (for dialysis) or a PIC line (for IV therapy) is not the intent Section Q. The coding intent is centered on: A.) whether or not the treatment or program was ordered. B.) if ordered was treatment of program carried out? C.) if program or treatment delivered- for how many days within the last 3 days? Possible coding options are: 0 = Not ordered and did not occur 1 = Ordered not implemented 2 = 1 or 2 days of last three days 3 = Daily in last 3 days Scenario 1 person has a fistula for dialysis, no dialysis has occurred in last 3 days, dialysis treatment has been ordered. Note: Fistula dressing change taking place at the time of dialysis is part of the treatment]. Fistula dressing has not been changed within last 3 days. Code = 1 for Dialysis Coe = 0 for Wound care Scenario 2 If fistula dressing is changed once, within the last 3 days, (outside the dressing change associated with the dialysis treatment) Code = 2 for Wound care Scenario 3 A person received IV medication on 1 of the last 3 days, no dressing change was done within last 3 days Code = 2 for IV medication Code = 0 for wound care A person could received IV medication without having a change of dressing on the PIC line Scenario 4 If a person has IV medication and the PIC line dressing was changed daily within the last 3 days (both occurring in the last 3 days). Code = 3 for IV medication Code = 3 for Wound care
18.) Section J - the Fatigue question- What if energy has nothing to do with why a participant does not choose to complete day to day task (cognition or choice) how should we code this?	PAULINE: Code is “None” For the last 3 days the person has not completed day to day tasks (ADLs, IADLs); The reason for not completing the daily tasks is due to something other than diminished energy. The code of “0” “none” is the appropriate response.
17.) Section K - How should we mark how a person eats if they take tube feedings and some oral nutrition or vice versa one supplements the other? Follow-up question: "Tube feedings are enteral, not parenteral. Can we have further clarification?"	PAULINE: The code is combined oral and parenteral tube feeding (A tube feeding is one of the possible types of parenteral feeding). The previous response contained an error. Thank you for picking up on this. The code is combined oral and parenteral or tube feeding.
16.) It has been explained to me that the Constipation CAP is triggered for some clients when we do not think it should be triggered. The question in the assessment asks if the client is constipated, and we answer present but not exhibited in the last 3 days for irregular and periodic episodes of constipation that have not affected the client within past 3 days, we get a trigger that the client has not had a bowel movement in the last 3 days and is at risk for....when this is not the case. Are we interpreting the question incorrectly?	PAULINE: This topic involves the use of interRAI HC triggers and the interRAI HC CAPs. See CAP Manual The Bowel Condition Clinical Assessment Protocol Deals with constipation, diarrhea and bowel incontinence Step 1: A. Risk of Decline in bowel status [constipation, diarrhea and bowel incontinence] B. Risk of Improvement in bowel status [constipation, diarrhea and bowel incontinence] Step 2: After the two types of risks are considered, there are three possible trigger outcomes: 1. Triggered with potential for improvement bowel status [constipation, diarrhea and bowel incontinence] 2. Triggered to prevent bowel status decline bowel status [constipation, diarrhea and bowel incontinence] 3. Not triggered Step 3: Follow “III Bowel CAP Guidelines: Assessment and Care Planning. The clinician needs to gather more information and determine if person has constipation, diarrhea or bowel incontinence, or a combination of these. By following the “Bowel Problem Assessment” the clinician proceeds to make this determination. On page 197, the clinician will find “Care Planning Suggestions” targeted to constipation diarrhea and bowel incontinence When the interRAI Bowel CAP is triggered, this does not automatically mean the person has that problem.
15.) Related to capacity scoring for stairs (section P under IADLs), none of the responses fit for someone that would never be able to do stairs (paras, quads, etc.). Should people just put dependent? Adding a response, like "Unable under any circumstance" would be a better fit. Our assessors have been leaving it as "No Selection" (blank) if they encounter this situation, but then it impacts other CAPs.	PAULINE: Stairs performance: code is “8” Activity did not occur during the entire period Stairs Capacity: Person with paraplegia, quadriplegia that has no capacity to do stairs, simply follows the directions right on the form Code of “8” states Activity did not occur during the entire period (NOT USED FOR CAPACITY) Therefore the code is “4” Total Dependence - full performance by others during the entire period. This instruction is also in the interRAI HC User Manual (which you have adapted for the MI use). The use of “No Selection” is not a part of the interRAI HC coding scheme for any item.
14.) Is the participants participation in ADL/IADL's (normal everyday activity, ex; walking room to room, out to yard, meal prep) count for hrs of activity in the three days, or does the participant have to have an intended "exercise" routine to count?	PAULINE: As per interRAI manual: Exercise or physical activity: any exercise that involves at least moderate physical activity, e.g., walking outdoors, swimming, yoga class, exercise with machines. In your question above you have listed “normal everyday activity” as walking room to room, out to yard, meal prep.
	Activity ♦	Qualifies as interRAI exercise or physical activity
	Walking room to room	No
	Daily walk in house-goal 200 steps per day	Yes
	Meal prep	No
	Picking apples with grandchildren	Yes
	Out to yard –yard work done	Yes
	Out to yard – person does 5 laps 4 days a week to help keep arthritic joints limber	Yes
	Yoga class	Yes
	Tai chi	Yes
	Walking outdoors	Yes
	Swimming	Yes
	Strength training	Yes
	Used seated stepper	Yes
	Used stationary exercise bike	Yes
	Doing usual ordinary housework	No
	♦ This list illustrates some of the possible exercise or physical activities; it is not a complete list. An assessor will check this item if a person has done the moderate exercise within the last 3 days. The exercise can be part of an organized program, or may be something the person is doing on his/her own.
13.) Clarification requested for IHC G4- Activity Level. Intent description indicates moderate activity in connection with "activities of everyday life". Definition states total hours of exercise or physical activity in last three days.	PAULINE: “Activities of everyday life” is a poor choice of words here. It serves to confuse the user. I will make a note that this needs to be corrected in future editions.
12.) What constitutes "apartment or house re-engineered accessible for persons with disabilities"?  Does this mean simply that home modifications have been made? And if so, to what degree does the apt/house need to have been made accessible i.e. do grab bars only count or must it be widened doorways, ramp, walk-in shower etc?	PAULINE: See my response above. InterRAI definition is very broad here.
11.) How should the Supports Coordinator determine whether to answer yes or no to from "Dehydrated"?	PAULINE: From the interRAI HC manual : Dehydrated---identifying dehydration can be difficult. Record your clinical judgment based upon signs and symptoms (e.g., severe vomiting over a period of time). Alternatively laboratory results (if available) indicating dehydration may be available (i.e., bun/creat ratio of >25). PBT additional comments: If person had severe diarrhea over a short period of time, this also could be an indicator of potential dehydration. Referral documents may list dehydration as one of the diagnoses. Remember, coding for dehydration on the interRAI form does not mean the person automatically has dehydration. We are not asking assessors to make a medical diagnosis here The dehydration condition may be triggered with the CAP identification process. At this point “dehydration” is a potential problem.” Bottom line -- if assessor does not find any indicators of a potential dehydration- don’t check this item.
10.) Sec D Environmental Section - Lives in apartment or house re-engineered accessible for persons with disabilities - does this pertain to having put in railings, grab bars, removal of shower doors for transfer bench, ramps, etc. or does it pertain to true handicap accessible apartments or homes, 2 separate treatments or is it considered the same?	PAULINE: Code “yes” if there has been any adaptations/re-engineering in the house or apartment or condo.
9.) Sec J Health Conditions - Balance - there is no option for someone who does not walk due to amputated limb(s), paralysis, etc. How is this handled?	PAULINE: The answer is “0” not present. Code of o may be used when person can not do any balance testing/activities.
8.) The whole pain thing and time frames is confusing. Clarification, please."	PAULINE: Page 8 Section on Pain Symptoms Time Frame: Last 3 days Applies to the following items in the PAIN Section: Pain Scale* Intensity of Highest Level of Pain Present Consistency of Pain Breakthrough Pain Pain Control Time Frame: last three days AND up to 30 days after the ARD (Assessment Reference Date) Applies to the following items in the PAIN Section: Frequency with which person complains or shows evidence of pain This item is the only one in the PAIN section to have the coding option of “present but not exhibited in last 3 days.”
7.) Pain (the first scale) - what time frame? (CIM note: we believe that "first scale" refers to Pain Frequency)	PAULINE: Page 8, Section on Pain Symptoms. Pain Scale * “Number from 0-10 that best describes pain in the last 3 days. 0 = no pain 5= Distressing Pain 10 = Unbearable pain These numbers (0,5,10) are points on a scale of 1-10 of course. The person being assessed needs to make the choice, if at all possible. The person uses whatever criteria they wish (frequency, intensity, multiple locations, degree of interference with daily life, etc.). Having the person look at a PAIN Visual Analog Scale and select the PAIN number really helps. With the PAIN Visual Analog Scale, you can also ask the person to point to the number that best describes his or her experience of pain in the last 3 days. The PAIN Visual Analog Scale may also be used with family, friends, and formal staff. PAIN ANALOG SCALE The above is a MOSBY© document. You can easily construct your own Visual Analog Scale for Michigan. Instead of listing the words “None, Mild, Moderate, Severe” as in the MOSBY© document, Michigan PAIN Visual Analog Scale would have the line across the page, numbers listed from 0-10, and the words underneath the scale would be: Under the # 0 “No pain” Under the # 5 “Distressing pain Under the # 10 “Unbearable pain” The Scale can then be printed it out and placed in a plastic sheet protector sleeve. The assessor can take the scale out and show it to the person (or other person sharing information) as they go through the pain items.
6.) Fever - what time frame are we looking at (if she had a fever but not in the last 3 days is that present or not)?	PAULINE: The use of the “present but not in the last 3 days” coding option is to be used for a time from of no more than 30 days beyond the Assessment Reference Date. This is what I said during the Michigan training. Example: ARD is 12-5-08 The last 3 days are 12-3-08, 12-4-08 and 12-5-08. Assessor determines person did not have a fever in the last 3 days. Person reports fever on 12-31-08 (26 days after the Assessment Reference Date). Code option # 1 Present, but not in last 3 days.
5.) We had removed all the life insurance questions on Page 2 of the Face Sheet in the earlier assessment when these items became optional. I must have missed coding these as optional when I filled out my forms for this assessment. (Or are they no longer optional?) Is it possible we can have them removed from our information when you do the next update? We have just been noting Life insurance information in the comment box-not collecting all the policy information "up front".	ELIZABETH: I have no problem making this an “agency add-on” item. I think I argued for keeping this information because it is very useful when doing re-determinations. I think it should be available for those who want it. If that's a change in my opinion, I apologize for any confusion. If I were a waiver agent, I'd argue to keep this information. However, sitting from my chair at "THE STATE" I can see how this goes beyond the MINIMUM Data Set.
4.) a. Current Payment Sources: Previous assessments called this Insurance Resource and we chose the primary insurance source overall (Medicare for most of our clients). This says the intent is to document sources of payment for home care services. Please clarify- our clients may have Millage-funded services, OSA-funded services, Medicaid, Medicare (but not have a skilled issue...). And, some may not have had a payor for home care services in the last 30 days, as the coding instructions describe. b. We are a bit unclear about the insurance question located on page 2 of the face sheet. On the old assessment, I believe we were to check the primary payment source. On this one it says "Current payment sources"-which to me indicates you would check all that apply? Many of our clients have Medicare as primary, Medicaid as secondary. This option appears-but folks are also wondering if they check the box that says Medicare and the box that says Medicaid and the box that says Medicare with Medicaid co-pays. And then they are unclear of how to code when there is another supplemental policy. Clarification?	ELIZABETH: The following is an excerpt from the IHC Manual, page 17 and it states: ~~~~~~~~~~~~~~~~~ A7. Current Payment Sources for Inpatient Stay [Example - USA] Intent: To document the sources of payment for home care services. Process: Consult with the business or billing office to review current payment sources used within the last 30 days. Do not rely exclusively on information recorded in the person’s service record (usually the face sheet at the front of the administrative or clinical record) as sources of payment may change while receiving services based on the person’s condition. Capture all methods of payment. Coding: Enter “1” for payers of services in the last 30 days; code “0” for all others. [Note: Billing office to indicate.] 0. No 1. Yes a.) Medicaid — Pays for nursing care and other necessary therapies or services. b.) Medicare — Pays for nursing care and other necessary therapies or services. c.) Self or family pays for full per diem cost — The person or family pays the full cost of care and services. d.) Medicare with Medicaid co-payment — The State is responsible for the Medicare co-payment. e.) Private insurance — The person’s private insurance company (e.g., LTC insurance) covers all or part of the cost of care and services. f.) Other per diem — Another entity covers all or part of the cost of care and services. ~~~~~~~~~~~~~~~~~~ Item #d in the above question refers to QMB/SLMB/ALMB's. This box should be checked if the person qualifies for any of those programs. The Supports Coordinators should check all boxes that apply.
3.) Is there any guidance or suggestions on documentation in the comments other than terse, concise and brief?	PAULINE: My “rule” is: "If you are the next caregiver to work with the person, what would you need to know that is not expressed within the appropriate section of the interRAI HC?”
2.) Does assistance with standing include mechanical assist such as sit to stand? At the training, it seemed that assistance was human help/touching. Would use of a lift or sit to stand unit be maximum assist?	PAULINE: The following is an excerpt from the HC Manual: 4.) Extensive assistance * Weight-bearing support (including lifting limbs) by 1 helper where person still performs 50% or more of subtasks 5.) Maximal assistance * Weight-bearing support (including lifting limbs) by 2+ helpers -OR- Weight-bearing support for more than 50% of subtasks 6.) Total dependence * Full performance by others during all episodes If a mechanical lift was used to transfer a person during the assessment time frame - use the definitions listed above to determine correct coding. When a mechanical lift is used- the possible codes are 4, 5 or 6. Example 1: person does not participate in any aspect of the transfer via mechanical lift (during bathing process). mechanical list is operated/used by a helper. therefore code for g.2.a is "6" total dependence. Example 2: During the last three days, the person has transferred from wheelchair to toilet (and reverse) with the assistance of one helper operating a mechanical lift. During each transfer on and off the toilet- the person stands up and bears some of his or her own weight. The person is doing part of the transfer, but more than 50% is done by helper and a mechanical lift therefore code for g.2.g *- is "5" maximal assistance. MARY: There are only 4 items in the MI version of the i-HC where transfer performance is coded: · Bathing · Transfer · Transfer toilet · Bed mobility ·
1.) Does PT and/or OT therapy or treatments or exercise plan count towards moderate physical activity (G.4. activity level)?	PAULINE: No. PT or OT therapy or treatments administered by a qualified therapist or by a qualified therapy assistant (under supervision of a therapist) are NOT a part of the activity level item. If the person being assessed has carried out parts of an exercise plan (perhaps developed by a PT or OT) within the assessment reference period, this could contribute to the coding of G.4 activity level.