The West Virginia Senior and Disabled Persons Assessment Pilot Project

The State of West Virginia engaged in a two year pilot project from September 2000-September 2002. The project was designed to improve the delivery of long-term care services to elders and adults with disabilities throughout West Virginia and to demonstrate the appropriateness of a selected, computerized, comprehensive assessment tool for statewide adoption across all long-term care programs.

The following five objectives were developed for the project:

• To provide point-of-care tools to comprehensively assess the current health status, psychosocial, preventive care, social service, and risk profiles of West Virginia’s senior and disabled populations.
• To assist in the determination of medical eligibility by recommending a level of care and insuring the most appropriate plan of care for Medicaid Waiver services.
• To provide a method of electronically communicating client health care information among health care providers for the efficient delivery of services across the continuum of care.
• To produce electronically retrievable data for statewide analysis, comparison of populations and services across populations, aggregate reporting for outcome studies, resource management and long range strategic planning.
• To provide access to additional Coupler technology in order to enhance the clinical decision-making, diagnosis and management of conditions common to individuals with chronic illnesses.

This project stemmed from recommendations made by the Interagency Long-Term Care Panel, a focus group formed in 1996 to address long-term care needs within West Virginia. This group was comprised of representatives from all of the agencies within State government with responsibility and authority for the provision, payment and regulation of long-term care services within West Virginia. The first objective identified by this group was that West Virginia needed to develop a common and standardized set of assessment instruments and processes for entry into the long-term care system.

A task force was created to draft and test a uniform assessment process in 1997 and 1998. In April 1999, members of the Interagency Long-Term Care Panel learned of the existence of a computerized assessment instrument developed by the Problem Knowledge Coupler Corporation (PKC) of Burlington, Vermont, being piloted in West Virginia and New York in a Center for Medicare and Medicaid Services controlled trial entitled Primary and Consumer - Directed Care for People with Chronic Illnesses. After extensive review of PKC’s “Senior Assessment Coupler”, the PKC Assessment instrument not only was determined to meet but also exceeded their objective, and recommended that it be further tested in West Virginia. The WVHCA was designated to oversee the pilot project and to underwrite the financial and administrative costs of the project.

The project involved 11 agencies within the State representing county senior programs, home health agencies and case management agencies.

Nurses and Social Workers from the agencies used the selected point-of-care tools to provide immediate access to evidence-based recommendations for improved care planning, care management and electronic sharing of necessary client information.

The information collected by the tool offered a detailed, individualized picture of older and younger disabled persons including family relations, lifestyle, legal resources and needs, functional health, cognition, nutrition, medical conditions, and personal plans were addressed as they affected clinical care and social interventions. Problems identified from this information were then “coupled” with the latest medical knowledge and the assessor was provided with action steps which were used by the consumer and care provider to guide the care planning and care management process, as well as educate the consumer about his or her healthcare options.

The data collected by the participants was submitted to the WVHCA on a monthly basis where it is housed in a database. This data was used to evaluate the pilot project in attaining its purpose and objectives.

The Senior Assessment Coupler was customized in the following manner to meet several State-specific needs.

• The West Virginia Nursing Home Level of Care Criteria was added to electronically document a client’s level of care profile.
• An additional sequence was added to incorporate all questions required for the WV PAS 2000 for Medicaid-covered long-term care services, including nursing homes. A custom Crystal Report was also created to automatically generate a PAS 2000 report to allow for electronic transmission to the appropriate state agencies.
• The Activities of Daily Living Rating Scale, a state-developed scoring tool used to rate the intensity of ADL dependency, was added to the software. This scale was used to determine hours of service authorized for the State-funded Personal Care Program. The SAC automatically scored the hours of service authorized, based upon the scoring methodology developed by the State, and documents the supporting client findings that contributed to that score.
• A comprehensive Body System Review component was added to meet specific CMS requirements for Home Health agencies.

Time frames for the project included:

Phase I - Planning and evaluation began in April 1999 through September 2002
Phase II -Selection and education of the pilot participants, February/March 2000
Phase III -Period of Performance: September 11, 2000 through September 11, 2002

Specific activities and operations of the program included: project Kick-off in June 2000, training for the participants and implementation in September 2000, monthly conference calls with pilot sites, submission of participant Senior Assessment Coupler data and activity reports, a minimum of 25 Senior Assessment Coupler sessions completed in client homes required by each participating agency, PKC and WVHCA telephone and onsite client support provided, Joint Application Design meeting in December 2000, Focus Group meetings in July 2001, Interim Project Evaluation in February 2001, Project Summary October 2001, and Project Completion September 2002.

The West Virginia Health Care Authority considers the demonstration project to be very successful by recognizing that the majority of the projects objectives were met. Overall, participating project agencies and the patients receiving care were satisfied with the PKC care management system.

The project concluded due to budgetary constrains and inability to find ownership for the future project expansion on day-to-day operations. Subsequently, participating agencies were able to continue to utilize the care management software through direct arrangements with PKC.

Click here to review the West Virginia Senior and Disabled Persons Assessment Coupler Pilot Project Summary for September 2000-September 2001.