LTC Claims Administration Toolbox
Section 3
On Site Assessment Tool
A. Introduction
The On Site Assessment tool (OSA) collects in-depth information about the insureds’
functioning, as well as their life and home situations. It is an instrumental tool in the
management of home health care and assisted living benefits, and to a lesser degree nursing
home benefits.
The OSA should provide the insurer with information that addresses, among other things,
three principal questions:
Are the policy triggers required to access benefits being met?
Does the plan of care (POC), provided by the facility, physician, and/or vendor,
determine specific objectives, goals, actions, and timelines designed to meet the insured’s
needs and help the insured achieve his or her maximum potential as identified through the
assessment process?
What types of services are required and with what frequency to effectively
implement the POC?
B. Discussion
This section of the toolbox includes 8 categories that would be included in a comprehensive
OSA. Where applicable we have provided commentary and tips on incorporating information
obtained into the overall assessment of the claim by the insurer. The categories are:
Personal
Medical History
ADL
IADL
Falls
Cognitive
Behavior and Emotions
Caregiver
Each category in the OSA represents a culmination of information gathered from the review
of 10 different OSAs used in the LTC industry. Each category was reviewed to identify if
there was additional information missing from the current OSAs reviewed that could improve
an LTC insurer’s ability to assess eligibility, POC, and ongoing claim management. Where
identified this new information has been added to enhance the effectiveness of the OSA tool.
Also, a new category, Fall Assessment, has been added.
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LTC Claims Administration Toolbox
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On Site Assessment Tool
C. On Site Assessment Tool
The sample OSA tool developed here provides LTC insurers with ideas of what could be
incorporated in their company’s OSA. Definitions are broad and must be tailored to match the
definitions of the individual company’s policies if any or all parts of the tools are used. The
simple style of formatting used is purposeful, so that the tool can be easily replicated or
reformatted should an insurer be interested in using any of this information in their own OSA
tool.
The sample On Site Assessment tool included here addresses only those areas related to
gathering functional, and cognitive information as well as other critical pieces of information
required to develop a plan of care specific to the insured’s needs. It does not include pages
that would provide policy information or any information that the insurer might obtain relating
to the assessor or the third party administrator.
D. ADL Assessment
The activities of daily living (ADL) section includes a “Prior” column. The information
collected to complete this section will typically be self reported by the insured or their legal
representative. It is important information as it is used for care planning purposes to
establish achievable goals when appropriate. If the policyholder is in an assisted living or
skilled nursing facility, the assessor should review the medical record including transfer
records if applicable, as well as all clinical documentation provided by physical, occupational,
and speech therapists to determine the insured’s “Prior” functional abilities. If there is no
information regarding “Prior” functional levels the assessor should mark unknown.
Other questions in this section include collecting information that is valuable as a benchmark
when establishing measurable goals in a Plan of Care, e.g. under dressing, the length of time
it takes to complete the dressing process at time of assessment.
E. Cognitive Assessment
Standardized Tests
The cognitive section of the OSA should contain both an objective/standardized screening
test and behavioral questions related to cognitive function. Insurers will decide which one of
the standardized tests that are available will be used as part of their OSA in order to
determine an insured’s cognitive status. Examples of objective/standardized tests are the
Mini-Mental State Examination (MMSE, also known as the “Folstein”), the MCAS, Delayed
Word Recall (DWR) or the Short Portable Mental Status Questionnaire (SPMSQ).
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Once the insurer has established which test they will be utilizing, the insurer needs to
establish what criteria meets each of the required benefit triggers as defined in their policy.
For instance, establishing the scores of the standardized selected by the insurer’s that
identifies severe, mild and moderate cognitive impairment right on the assessment tool (see
tool for example) provides objective and consistent determinations on this component of the
assessment.
Some insurers may wish to include a second generally accepted standardized test in their
claim administrative policy when the documentation received to determine eligibility for
benefits is not clear or conflicts with the primary test that has been obtained. The insurer
should establish a policy with how to proceed if the second test conflicts with the first.
Some insurers may wish to consider other testing which may not be considered “generally
accepted” because they are:
a) new and not widely used in the clinical or insurance communities;
b) are purely propriety in nature; or
c) cannot be easily found in the “common” medical journals or websites.
While many cognitive tests are emerging and may be appropriate for claim determinations,
the insurer should consider the following risks when selecting a “standardized” test for
cognitive evaluation:
a) Is it medically accurate? Consider factors such as sensitivity, specificity, and risk
of assessor error.
b) What is the insurer’s tolerance to customer complaints, litigation and public
relations risk?
c) How suited is the test to procedures, workflows, policyholder skills and vendor
capabilities?
Behavioral/Judgment Questions
The questions used in this section need to be clear enough and include sufficient assessor
instructions to limit interpretive errors by the on-site assessor.
When insurers ask Behavioral/Judgment questions as part of the cognitive assessment they
need to establish clear procedures to rate or score these questions for the purpose of
determining how the responses would indicate poor judgment, deficient deductive and
abstract reasoning, and or indicate threat to safety and health. This is critical to minimize
subjective interpretation by assessors and reduce variability across assessors responsible for
determining if the benefit triggers have been met.
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On Site Assessment Tool
Certification for Tax Qualified (TQ) Policies
If the insurer will be asking the on-site assessor to do the TQ certification, there should be
clear instruction and clarification of terms used in this certification process to limit assessor
variability. Therefore the insurer needs to establish what meets each of the required benefit
triggers as defined in their policy and include this information in the certification document.
The cognitive section of the TQ certification document should be written in a manner that
clearly shows that certification requires that the insured have both “severe” cognitive
impairment AND require “substantial supervision”; the latter being defined by the IRS as
meaning continual.
An example of assessor instructions to include in a certification document for TQ certification
follows. If an insurer’s definitions are different from above or the insurer’s triggers differ, the
instructions and actual certification would be altered from those below to reflect the
differences. The example reflects the use of the MMSE as the standardized test:
TQ certification requires that the claimant have BOTH “severe” cognitive impairment
AND to require “substantial” (IRS defined as CONTINUAL) supervision to protect the
claimant from threats to their health and safety.
• Severe cognitive impairment is demonstrated by an MMSE* score of 0 - 10
or a score of 11 - 23 in conjunction with behavior problems consistent with
severe cognitive impairment such as those in the “behavioral questions”
section that pose a threat to the claimant’s health and safety.
• SUBSTANTIAL supervision requires that the supervision be CONTINUAL.
Intermittent or periodic supervision such as only a daily medication reminder
or telling a claimant they have a doctor’s appointment are not continual or
continuous in nature and are therefore not generally considered “substantial”
in nature.
Examples of certification statements based on MMSE* scoring:
A. I certify this claimant has a SEVERE cognitive impairment as documented by either
an MMSE score of 0 - 10 alone or an MMSE score of 11 - 23 in addition to known
behavior problems consistent with severe cognitive impairment AND requires
SUBSTANTIAL (defined as continual) supervision to protect this SEVERELY
cognitively impaired claimant from threats to their health or safety.
Yes ______ No _______
B. I certify this claimant requires SUBSTANTIAL (IRS defines as CONTINUAL)
supervision to protect this SEVERELY cognitively impaired claimant from threats to
their health or safety. SEVERE cognitive impairment is documented by either an
MMSE score of 0 - 10 alone or by an MMSE score of 11 - 23 in addition to known
behavioral problems that threaten their health or safety.
Yes ______
No _______
* If using a test other than the MMSE, substitute the appropriate scores to both the Scoring
Section on the actual cognitive test used in the assessment and in the actual certification
statement.
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LTC Claims Administration Toolbox
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On Site Assessment Tool
F. Fall Risk (Frailty) Assessment
The terms frail, or fear of falling are often use when describing why an insured requires
assistance with ADL activities. The definitions of frailty describe things such as “a
freestanding syndrome marked by loss of function, strength, and physiologic reserve and
increased vulnerability to falls, sickness and death” or “inactivity, weight loss and decline in
functionality (grip strength, walking speed, exhaustion, etc.).” Some definitions also include
depression, isolation, “a lack of drive,” or “loss of interest in activities, family or friends.”
A Fall Risk Assessment provides valuable insight into possible causes for falls resulting in
injuries leading to the inability to complete ADL functions. A Fall Risk Assessment when
combined with the other information collected in the OSA provides a complete picture of the
insured’s physical and emotional status, and contributory environmental factors that put them
at risk. This additional information is incorporated in the POC and becomes key in promoting
independence. For those who have come on claim as a result of an injury due to a fall, the
information gathered from this assessment can help prevent a return to claim if the cause of
fall can be addressed through the POC.
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