Support Plan Materials

Integrated Intake and Assessment Materials Page

Integrated Intake and Assessment Materials Page

The Department, HCBS Strategies, stakeholders, and case managers have been diligently working to develop a single intake and assessment process that will be used to identify level of care and service needs for all long term service and support (LTSS) populations. 

Below are historic versions of the Intake Screen and Assessment modules from June 2018 as well as draft updates from February 2020. 

  • Intake Screen: Collects basic information about the individual. Information obtained through the Screen is used to inform whether the individual should receive an assessment.
    • 2018 version can be found here.
    • 2020 version can be found here. 
  • Level of Care Screen: This module pulls the items necessary to determine and verify that the participant meets level of care (LOC) prior to completing the broader assessment.
    • 2018 draft version of the module can be found here. 
    • 2020 draft version of the module can be found here
  • Personal Story: Allows the participant an opportunity to provide information that she or he feels is important for providers and others providing support to know.  This module is voluntary and is planned to be available online.  Participants could complete this module at their convenience online or could enlist help from the assessor during the assessment process.  This information is collected early in the process so that the assessor can consider the participant’s goals and objectives from the beginning of the assessment and support planning process.  Two versions of this module were developed, 1) for participants ages 0-7 and those with significant cognitive impairments and 2) participants ages 8+ without significant cognitive impairments.
    • 2018 draft version of the module can be found here. 
    • 2020 version of the module for individuals age 0-7 can be found here. 
    • 2020 version of the module for individuals age 8+ can be found here. 
  • Case Manager Introduction: Facilitates a discussion between the case manager and participant around which assessment path, Brief or Comprehensive, the participant would like to follow.
    • 2018 draft version of the module can be found here. 
    • 2020 draft version of the module can be found here. 
  • Basic Assessment: The Basic Assessment will go over only the items that are mandatory for us to discuss to determine your eligibility for services and develop your Support Plan. While this is a shorter assessment, we will not discuss in-depth your preferences for how services are delivered or talk about other areas that LTSS supports are available beyond those areas that address your personal goals and health and safety needs. The Basic Assessment will still result in a comprehensive Support Plan, however it will be limited to the topics that we cover within the mandatory items and information you choose to share. Participants who may be appropriate to forego the Comprehensive assessment include: 1) Participants who are currently receiving services and are very familiar with the spectrum of LTSS offered in Colorado and 2)  Participants who are only looking for specific services and are not interested in any additional supports. A draft version of the module, last updated on 6/30/18, can be found here. Because this module is comprised only of items from other modules in the Comprehensive Assessment, the 2020 version of this module will be posted after all draft changes to the Comprehensive Assessment are finalized.
  • Functioning:  There are two versions of the functioning module that are tailored to specific age groups: ages 0-3 and 4+. The version of the module for individuals age 0-3 assesses Activities of Daily Living (ADL) tasks and impact on functioning. The version for individuals age 4+ is similar to the adult module. This version contains items to assess the needs, strengths and preferences of the participant in performing and receiving support for 1) Activities of Daily Living (ADL) such as dressing, eating and bathing, and 2) Instrumental Activities of Daily Living (IADL) such as housekeeping, meal preparation and shopping.  The module also includes needs for training or assistive devices to increase independence whenever possible. Specific items are skipped based on the individual’s age.
    • 2018 version of the module for individuals age 0-3 can be found here. 
    • 2020 version of the module for individuals age 0-3 can be found here. 
    • 2018 version of the module for individuals age 4+ can be found here. 
    • 2020 version of the module for individuals age 4+ can be found here. 

  • Health: Contains items to assess health status of the participant and needs for support or treatment to maintain health.  This module appears as the longest, however, many areas can be skipped over if there are no health issues. This module also offers brief screening for 1) health risks that could indicate a need for further follow-up with a physician or agency, and 2) undiagnosed brain injury (traumatic or acquired).
    • 2018 version of the module can be found here
    • 2020 version of the module can be found here
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  • Memory and Cognition:  Contains items to assess the current functional status of the person to recall and understand information, make judgments, express ideas, and make decisions necessary for daily life.
    • 2018 draft version of the module can be found here
    • 2020 draft version of the module can be found here
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  • Psychosocial:  Contains items to assess the presence and intensity of behavioral needs  and provides an initial screening to determine the need for a referral to assess and treat depression, suicide and substance abuse, compulsive gambling, and tobacco usage.
    • 2018 draft version of the module can be found here.
    • 2020 draft version of the module can be found here.
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  • Sensory and Communication:  Contains items related to hearing and vision, functional communication, and sensory integration.  In addition to looking at needs, this module considers training and assistive devices to increase independence and community inclusion. In addition to the core module, a supplement has been developed to collect age-specific information about functioning.
    • 2018 draft version of the module can be found here 
    • 2020 draft version of the module can be found here 
    • 2018 draft version of the supplement can be found here.
    • 2020 draft version of the supplement can be found here.

  • Employment, Volunteering and Training (EVT):  Contains items to explore interests in work, a volunteer position, or education and training opportunities and to find out what barriers exist for the participant in those areas.  The items will also help to identify the support needed to achieve the outcomes the participant would like to see.
    • 2018 version can be found here
    • 2020 version can be found here.

  • Housing and Environment:  Contains items related to the participant’s current living situation, environmental safety and quality, and interests/needs for housing and environment that support and maximize independence of the participant.  This module also helps to identify transitional needs for individuals leaving institutions or hospitals or those who may be in temporary housing or be homeless.
    • 2018 version of the module can be found here
    • 2020 draft version of the module can be found here

  • Participant Engagement:  Contains items for determining the participant’s desire and needs related to advocacy.  This includes looking at the need/desire for training and assistance to enhance engagement and control of service planning and service delivery.  This module also identifies individual preferences for how information about services is obtained and interest in participant direction. Two versions of this module were developed, 1) for participants ages 0-13 and those with significant cognitive impairments and 2) participants ages 14+ without significant cognitive impairments.
    • 2018 draft version of the module can be found here.
    • 2020 version of the module for individuals age 0-13 can be found here
    • 2020 version of the module for individuals age 14+ can be found here
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  • Safety and Self-preservation:  Contains items to help evaluate the participant’s capacity and need for assistance in personal safety and self-preservation.  This module addresses the need for supervision and oversight.  It also includes items about the need for training to avoid abuse, neglect or exploitation and the supports necessary to ensure the health and welfare of the individual. The 2020 version of the module incorporates the former Assessment Summary modules, which collects information about supervision and support needs across a variety of settings, including home, community, and day programs, and provides space for assessors to document additional information that was not covered in the assessment.
    • 2018 draft version of the Safety and Self Preservation  module can be found here.
    • 2018 draft version of the Assessment Summary module can be found here.
    • 2020 draft version of the module can be found here.
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  • Caregiver:  Contains items to assess the level of support provided by informal caregiver(s) and is designed to be used to 1) identify situations in which relief or support is critical to the continuation of informal caregiving and 2) identify situations in which paid supports should be initiated.
    • 2018 version can be found here. 
    • 2020 version can be found here

  • Hospital Level of Care Summary: The purpose of the Hospital Level of Care (LOC) Supplement is to identify participants who may need additional supports because of medical complexity and/or fragility and meet Hospital LOC.
    • 2018 draft version of the module can be found here.
    • 2020 draft version of the module can be found here.  

Assessment & Support Plan (A/SP) Pilot Information

Assessment & Support Plan (A/SP) Pilot Information

The Department of Health Care Policy and Financing (the Department) revising its assessment and support planning processes to create a more comprehensive, person-centered process that uses items with established reliability and validity. To test the contents of this process, the Department is conducting a series of statewide pilots with case managers from a variety of agencies to test the content and automation of Colorado’s new assessment and support planning process for long term services and supports (LTSS). 

These pilots will occur in two primary phases to capture data from four primary populations: children; individuals with IDD; individuals who are elderly, blind, or disabled (EBD); and individuals who experience mental health needs. The pilot steps and timeframe can be found in the graphic below:

The pilots are further described below.

Pilot Phase 1

The first phase of the pilot will occur in the Aerial CarePlanner tool, which is not the primary system that will be used upon rollout. This system, CarePlanner 360, is currently being finalized and will be implemented prior to phase two.

The first component of the first phase of this testing will be the level of care (LOC) pilot. During the LOC pilot, case managers will be using both the ULTC 100.2 and the new LOC pilot screening tool. The purpose of the pilot is to be able to compare responses in across the current and new items. The pilot will also provide valuable information about how user friendly the current automation is.  The Department will use this information to determine how to structure the pilots for the rest of the new assessment and support planning process. During this phase case managers will conduct approximately 1-2 LOC Screens for a total of 85 samples. 

The second component of the first phase is the Nursing Facility (NF)/Hospital (H) LOC and Reliability Pilot (NF/H-LOC & Reliability Pilot). This pilot will collect data necessary to fulfill the following functions:

  • Replicating the NF-LOC for adults 
  • Establishing a more objective NF-LOC criteria for children
  • Establishing objective and prospective H LOC for all of Colorado’s HCBS waivers
  • Testing the reliability, including the inter-rater reliability, of select items in the new assessment potentially used for NF-LOC, H LOC, and resource allocation

During this phase case managers will be conducting approximately 6-8 assessments for a total of 275 single assessor assessments and 150 paired assessors assessments. The paired assessor assessments will provide insight on inter-rater reliability. 

Pilot Phase 2

The second phase will assess the workflow of the process using the automation that is intended to be used in the field, CarePlanner 360. During this pilot, a smaller group of case managers (approximately 26) will conduct the comprehensive assessment and support plan (A/SP). This phase includes the following sub-phases:

  1. Case managers will first be introduced to the comprehensive assessment.  After receiving training, they will conduct this assessment on a minimum of two participants.
  1. Case managers will then be trained on the Support Plan.  They will be expected to conduct comprehensive assessments and develop Support Plans with three participants.
  1. The data from the first two steps will be analyzed and the first group of feedback sessions will be conducted with case managers and participants.  The assessment and Support Plan will be updated based on these results and the changes will be incorporated into the automation. 
  2. The case managers will be trained on the updates and will begin working with participants as part of the Time Survey pilot. This pilot will collect data to understand how long the new process takes.  A second waver of feedback sessions with participants and case managers will be conducted during this step.

This pilot will collect 48 samples for the comprehensive assessment, 78 samples for the entire A/SP process, and 100 samples of the A/SP for the Time Study sub-pilot. 

Colorado Assessment Tool Development Blog

Welcome to the Colorado Assessment Tool Development Blog.

Project Overview

The Colorado Department of Health Care Policy and Financing (HCPF) has contracted with HCBS Strategies to develop a new process for assessing the need for long term supports and services (LTSS).  

HCPF recognized that stakeholder feedback and buy-in is a key component of this work. This blog helps support this process by providing a place where all presentations and notes from stakeholder meetings will be made publicly available.  Stakeholders are invited to provide feedback directly on this blog by clicking here.

The project has the following stages:

  1. Understanding how Colorado’s current LTSS assessment processes
     work
  2. Develop a document that identifies how the new assessment process
    can support Colorado’s home and community-based services (HCBS)
    systems change efforts (formerly the white paper)
  3. Selecting the tool or tools that will serve as the basis of the new
    assessment process
  4. Customizing the tool or tools to meet Colorado’s unique needs
  5. Piloting the tool to understand the impact on eligibility
    determinations
  6. Developing a plan for implementing the new tool and related
    processes

The operational review mentioned in Step 1 has been complete, and during this process it was found that there are far more initiatives working towards systems change across the State than originally anticipated. As a result, the timing of the white paper (Step 2) was moved forward and refocused to discuss how the new assessment process might support proposed systems change efforts. The Department has decided on the tools that they will be using as models to develop their own tool (Step 3), and the draft assessment tools and training manuals have been developed (Step 4). As an additional part of Step 4, HCPF and HCBS Strategies worked with stakeholders to adapt and develop items and modules specific to children (0-18). This will allow the Department to have a comprehensive assessment tool for child LTSS populations, and also allow individuals to more easily transition from children to adult services. 

These draft consolidated modules can be found here.  Updates to the accompanying training materials are ongoing as updates to the modules occur during Support Plan development. Sample training manuals can be found here

As a final piece of Step 4, the Department worked with stakeholders to develop the Support Plan that will be produced after the Assessment. To view Support Plan materials, click here. The Support Plan was tested via a small workflow pilot in late Spring of 2018 (A component of Step 5). Piloting of the Assessment and Support Plan process began in February 2019 and will continue through May of 2020.