Updating the PAS for Children Under 6 Public Hearing The Pacific Health Policy Group October 12,...

Updating the PAS for Children Under 6

Public Hearing

The Pacific Health Policy GroupOctober 12, 2010

THE PACIFIC HEALTH POLICY GROUP

UPDATED PAS FOR CHILDREN UNDER 6Topics

1. Background and objectives

2. Updated PAS development steps

3. What’s changing and what isn’t

4. Updated developmental milestones

5. Updated algorithm and weights

6. Maintenance of Effort

7. Questions2








7. Questions3



AHCCCS uses a comprehensive pre-admission screen (PAS) and score to determine eligibility for the ALTCS program

AHCCCS was an early adopter of objective, score-based clinical eligibility criteria (becoming the national norm)

Instruments should be updated periodically to reflect latest research

PAS for children under age 6 last updated in 1995

Research on measuring childhood development has continued in the intervening years

4

UPDATED PAS FOR CHILDREN UNDER 6Background


Ensure that the PAS continues to properly identify children who meet the standard for eligibility (which is not changing): Immediate risk of institutionalization in an ICF/MR (regardless of actual service setting)

Incorporate latest research in measurement of age-appropriate developmental milestones

Replace adult-oriented independent living skill, communication and behavior items with age-appropriate developmental milestones

Update measurement of Autism Spectrum Disorder-related behaviors and developmental issues

5

UPDATED PAS FOR CHILDREN UNDER 6Objectives








7. Questions6



Expert panel convened, including independent developmental pediatricians, PHPG consultants and senior AHCCCS assessors and managers

Research conducted on nationally-recognized and validated studies and instruments (e.g., Ages & Stages, Vineland-II, ICAP, CDC Guidelines, MCHAT)

Developmental section revised and significantly expanded

Pilot study data collected over five months (770 cases)

Statistical analysis performed to construct new scoring algorithm, with age-specific weights

Preliminary algorithm reviewed by experts to ensure clinical soundness

7

UPDATED PAS FOR CHILDREN UNDER 6Development Steps








7. Questions8



A single PAS for all children under age 6

Greater use of developmental milestones (with new milestones added at more frequent age intervals)

New variables that recognize behaviors or developmental delays related to ASD are being recognized through the scoring algorithm

Use of age-appropriate developmental milestones in place of adult-oriented variables

Updated weights for variables carried over from the previous PAS instruments

9

UPDATED PAS FOR CHILDREN UNDER 6What is Changing?


The PAS assessment process

Medical section of PAS (scoring and weights have been updated)

40 point threshold for eligibility

Use of physician review

Eligibility standard: Immediate risk of institutionalization in an ICF/MR (regardless of actual service setting)

10

UPDATED PAS FOR CHILDREN UNDER 6What is Staying the Same?








7. Questions11


THE PACIFIC HEALTH POLICY GROUP 12

Domain Examples

Gross Motor Skills Does your child walk up stairs, using only one foot on each stair?

Fine Motor Skills Does your child turn the pages of a book one at a time?

Communication Does your child state their own first name or nickname?

Socialization Does your child know if s/he is a boy or a girl?

Daily Living Skills Does your child pull up clothing with elastic waistbands?

Behaviors Does your child stare at nothing or wander with no purpose?

UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestone Domains


# Milestone Applies to:

1Does your child lift their head when lying on their back?

6 months & older

2When your child is on their tummy, does s/he straighten both arms and push their whole chest off the floor?

6 months & older

3If you hold both hands just to balance your child, does s/he support their own weight while standing? (That is, can s/he bear weight?

6 months & older

4 Does your child reach for or grasp a toy? 6 months & older

5

Does your child try to pick up a crumb or Cheerio by using their thumb and all their fingers in a raking motion, even if they aren’t able to pick it up? (If they already pick up the crumb or Cheerio, check “yes” for this item.)

6 months & older

6 Does your child make high-pitched squeals? 6 months & older

7Does your child show two or more emotions? (For example, laughs, cries, screams etc.)

6 months & older

UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones



8

Does your child act differently toward strangers than s/he does with you and other familiar people? (Reactions to strangers may include, for example, staring, frowning, withdrawing or crying.)

6 months & older

9Does your child stiffen and arch their back when picked up? Reverse scoring

6 months & older

10Does your child roll from their back to their tummy, getting both arms out from under them?

9 months & older

11When you stand your child next to furniture or the crib rail, does s/he stand, holding onto the furniture for support

9 months & older

12Does your child creep or move on their stomach across the floor?

9 months & older

13Does your child sit supported (for example, in a chair with pillows etc.) for at least 1 minute?

9 months & older

14When a loud noise occurs, does your child respond? (For example, act startled, cry or turn toward the sound.)

9 months & older




15If you call your child when you are out of their line-of-sight, does s/he look in the direction of your voice?

9 months & older

16Does your child make non-word sounds? (That is, babble or jabber.)

9 months & older

17Does your child look toward you (parent or caregiver) when hearing your (parent or caregiver’s) voice?

9 months & older

18 Does your child enjoy playing peek-a-boo/pat-a-cake? 9 months & older

19 Does your child feed themselves a cracker or cookie? 9 months & older

20Does your child walk around the furniture while holding on with one hand?

12 months & older

21Does your child crawl at least 5 feet on hands and knees, without stomach touching the floor?

12 months & older

22 Does your child hold a bottle or cup? 12 months & older

23Does your child move an object from one hand to the other?

12 months & older




24Does your child pick up a small object with thumb and fingers?

12 months & older

25Does your child coo or laugh or make other sounds of pleasure?

12 months & older

26Does your child reach for familiar person when person holds out arms to them?

12 months & older

27Does your child play with a doll or stuffed animal by hugging it?

12 months & older

28Does your child suck or chew on finger foods? (For example, crackers, cookies, toast etc.)

12 months & older

29Does your child stand up in the middle of the room by themselves and take several steps forward?

18 months & older

30 Does your child climb on furniture? 18 months & older

31Does your child turn the pages of a board, cloth or paper book by himself/herself? (S/he may turn more than one page at a time.)

18 months & older




32Without showing them how, does your child scribble back and forth when you give them a crayon (or pencil or pen)?

18 months & older

33Does your child stack a small toy, block, cup, dish or other object on top of another one?

18 months & older

34 Does your child respond to their name when you call? 18 months & older

35When playing with sounds, does your child make grunting, growling or deep-toned sounds?

18 months & older

36Does your child say “Da-da” or “Ma-ma” or another name for parent or caregiver (including parent’s or caregiver’s first name or nickname)?

18 months & older

37

When you ask your child to point to their nose, eyes, hair, feet, ears and so forth, does your child correctly point to at least one body part? (They can point to themselves, you or a doll.)

18 months & older

38If you point at a toy across the room, does your child look at it?

18 months & older




39Does your child ever use their index finger to point, to indicate interest in something?

18 months & older

40 Does your child ever bring objects over to you? 18 months & older

41Does your child imitate you? For example, you make a face – will your child imitate it?

18 months & older

42 Does your child take an interest in other children? 18 months & older

43Does your child eat solid foods? (For example, cooked vegetables, chopped meats etc.)

18 months & older

44 Does your child like being hugged or cuddled? 18 months & older

45 Does your child run? 24 months & older

46Does your child jump, with both feet leaving the floor at the same time? (That is, can s/he jump up?)

24 months & older

47 Does your child flip light switches off and on? 24 months & older

48Does your child put up a small object in a cup and dump it out? (You may show them how.)

24 months & older




49Does your child stack at least four small toys, blocks, cups, dishes or other objects on top of each other?

24 months & older

50Does your child name at least three objects? (For example, bottle, dog, favorite toy etc.)

24 months & older

51Does your child follow instructions with one action and one object? (For example, “Bring me the book”; “Close the door” etc.)

24 months & older

52Does your child demonstrate understanding of the meaning of no, or word or gesture with the same meaning? (For example, stops current activity briefly.)

24 months & older

53Does your child copy the activities you do, such as wipe up a spill, sweep, shave or comb hair?

24 months & older

54Does your child play near another child, each doing different things?

24 months & older

55Does your child hold and drink from a cup or glass? (Includes “sippy” cups.)

24 months & older

56 Does your child look at you when you talk to them? 24 months & older



# Milestone Applies to:57 While standing, does your child throw a ball or toy? 30 months & older

58Does your child ask questions beginning with what or where? (For example, “What’s that?”; “Where doggie go?” etc.)

30 months & older

59Does your child call themselves “I” or “me” more often than their own name? (For example, “I do it” more than “Mary (John) do it”.)

30 months & older

60Does your child take off clothing that opens in the front (for example, a coat or sweater)? (Does not have to unbutton or unzip the clothing.)

30 months & older

61 Does your child use a spoon to feed themselves? 30 months & older

62Does your child sleep at least 8 hours in a 24-hour period?

30 months & older

63Does your child do things over and over and can’t seem to stop? (Examples are rocking, hand flapping or spinning.) Reverse Scoring

30 months & older




64Does your child destroy or damage things on purpose? Reverse Scoring

30 months & older

65Does your child hurt themselves on purpose? Reverse Scoring

30 months & older

66Does your child stand (balance) on one foot for about 1 second without holding onto anything?

36 months & older

67

Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) S/he may hold onto the railing or wall.

36 months & older

68 Does your child turn the pages of a book one at a time? 36 months & older

69Does your child use simple words to describe things? (For example, dirty, pretty, big, loud etc.)

36 months & older

70Does your child state their own first name or nickname?

36 months & older




71

Does your child follow instructions with two actions or an action and two objects? (For example, “Bring me the crayons and the paper”; “Sit down and eat your lunch” etc.)

36 months & older

72

Does your child pretend objects are something else? (For example, does your child hold a cup to their ear, pretending it is a telephone? Does s/he put a box on their head, pretending it is a hat? Does s/he use a block or small toy to stir food?)

36 months & older

73 Does your child know if s/he is a boy or a girl? 36 months & older

74Does your child pull up clothing with elastic waistbands? (For example, underwear or sweatpants.)

36 months & older

75 Does your child suck from a straw? 36 months & older

76Does your child cry, scream or have tantrums that last for 30 minutes or longer? Reverse Scoring

36 months & older

77Does your child act physically aggressive? (For example, hits, kicks, bites etc.) Reverse Scoring

36 months & older




78Does your child have eating difficulties? (For example, eats too fast or too slowly, hoards food, overeats, refuses to eat etc.) Reverse Scoring

36 months & older

79Does your child sometimes stare at nothing or wander with no purpose? Reverse Scoring

36 months & older

80 Does your child hop up and down on one foot? 48 months & older

81Does your child pedal a tricycle or other three-wheeled toy at least 6 feet?

48 months & older

82

Does your child walk down stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) S/he may hold onto the railing or wall.

48 months & older

83Does your child wiggle their thumb, for example when using a tv-remote controller or video game controller?

48 months & older

84Does your child unbutton one or more buttons, or unfasten one or more Velcro straps? Your child may use their own clothing or a doll’s clothing.

48 months & older




85Does your child use in, on or under in phrases or sentences? (For example, “Ball go under chair”; “Put it on the table” etc.)

48 months & older

86 Does your child say their first and last name? 48 months & older

87Does your child follow instructions in “if-then” form? (For example, “If you want to play outside, then put your things away” etc.)

48 months & older

88 Does your child share toys or possessions when asked? 48 months & older

89

Does your child tell you the names of two or more playmates, including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)

48 months & older

90 Does your child brush their teeth? 48 months & older

91 Does your child urinate in a toilet or potty chair? 48 months & older

92 Does your child defecate in a toilet or potty chair? 48 months & older




93Does your child put on clothing that opens in the front (for example a coat or sweater)? (Does not have to button or zip the clothing.)

48 months & older

94Does your child open doors by turning door knobs? (Includes doors that open/close with levers rather than traditional round knobs.)

60 months & older

95Does your child identify and name most common colors (that is, red, blue, green, yellow)?

60 months & older

96Does your child follow three-part instructions? (For example, “Brush your teeth, get dressed and make your bed” etc.)

60 months & older

97Does your child take turns when asked while playing games or sports?

60 months & older

98Does your child play informal group games? (For example, hide-and-seek, tag, jump rope, catch etc.)

60 months & older

99Does your child put shoes on correct feet? (Does not need to tie laces.)

60 months & older




100Does your child wash their hands using soap and water? (May be reminded.)

60 months & older

101Does your child use the toilet by themselves? (S/he goes to the bathroom, sits on the toilet, wipes and flushes. May be reminded.)

60 months & older









7. Questions27



UPDATED PAS FOR CHILDREN UNDER 6Algorithm & Weights – Developmental Milestones

28

6 - 8 Mos9 – 11 Mos

12 – 17 Mos

18 – 23 Mos

24 – 29 Mos

30 – 35 Mos

36 – 47 Mos

48 – 59 Mos

60+ Mos

Age Cohort

9 milestones

19 milestones

28 milestones

44 milestones

56 milestones

65 milestones

79 milestones

93 milestones

101milestones

6 - 8 Mos 5.000

9 – 11 Mos 4.100 4.100

12 – 17 Mos 2.900 2.900 2.900

18 – 23 Mos 2.125 2.125 2.125 2.125

24 – 29 Mos 1.750 1.750 1.750 1.750 1.750

30 – 35 Mos 1.550 1.550 1.550 1.550 1.550 1.550

36 – 47 Mos 1.340 1.340 1.340 1.340 1.340 1.340 1.340

48 – 59 Mos 1.140 1.140 1.140 1.140 1.140 1.140 1.140 1.140

60 Mos+ 1.030 1.030 1.030 1.030 1.030 1.030 1.030 1.030 1.030


UPDATED PAS FOR CHILDREN UNDER 6 Algorithm & Weights – Medical

29

Medical Conditions / Medical + Developmental Combinations

Age CohortCerebral

PalsyEpilepsy

Moderate/ Severe/

Profound MR

Autism + MCHAT-Related*

Autism + Behaviors*

6 – 8 Mos 5.0 5.0

9 – 11 Mos 5.0 5.0

12 – 17 Mos 5.0 5.0

18 – 23 Mos 5.0 5.0 7.0

24 – 29 Mos 5.0 5.0 7.0

30 – 35 Mos 5.0 5.0 7.0 5.0

36 – 47 Mos 5.0 5.0 15.0 7.0 10.0

48 – 59 Mos 5.0 5.0 15.0 7.0 10.0

60 Mos+ 5.0 5.0 15.0 7.0 10.0

*See next slides for definitions


Autism + MCHAT-Related – 18 months & Older Diagnosis of Autism, PDD or Autism-like behaviors Fails at least six of the following MCHAT-related milestones:

Does your child respond to their name when you call? If you point at a toy across the room, does your child look at it? Does your child ever use their index finger to point, to indicate

interest in something? Does your child ever bring objects over to you? Does your child ever imitate you? For example, you make a face –

will your child imitate it? Does your child take an interest in other children? Does your child like being hugged or cuddled? Does your child look at you when you talk to them? (Milestone

introduced at 24 months)

Note: Milestones also are scored individually and count toward 40-point threshold 30

UPDATED PAS FOR CHILDREN UNDER 6Algorithm & Weights – Detailed Criteria


Autism + Behaviors – 30 to 35 Months Diagnosis of Autism, PDD or Autism-like behaviors

Exhibits at least three of the following behaviors: Does your child sleep at least 8 hours in a 24-hour period? (“No”

response indicates presence of behavior)

Does your child do things over and over and can’t seem to stop? (Examples are rocking, hand flapping or spinning)

Does your child destroy or damage things on purpose?

Does your child hurt themselves on purpose?

Note: Milestones also are scored individually and count toward 40-point threshold

31



Autism + Behaviors – 36 Months & Older Diagnosis of Autism, PDD or Autism-like behaviors Exhibits at least six of the following behaviors:

Does your child sleep at least 8 hours in a 24-hour period? Does your child do things over and over and can’t seem to stop? Does your child destroy or damage things on purpose? Does your child hurt themselves on purpose? Does your child cry, scream or have tantrums that last for 30

minutes or longer? Does your child act physically aggressive? (For example, hits, kicks,

bites etc.) Does your child have eating difficulties? (For example, eats too fast

or too slowly, hoards food, overeats, refuses to eat etc.) Does your child sometimes stare at nothing or wander with no

purpose?

Note: Milestones also are scored and count toward 40-point threshold

32



Services and Treatments

Age Cohort

Drug Reg. and

Admin.

Non-B/B Ostomy

Care

Tube Feeding

PT or OT*Acute

Hospital Admits**

Direct Care Staff Train

Special Diet

6 – 8 Mos 1.0 7.0 7.0 1.0 1 x # 0.5 2.0

9 – 11 Mos 1.0 7.0 7.0 1.0 1 x # 0.5 2.0

12 – 17 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0

18 – 23 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0

24 – 29 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0

30 – 35 Mos 1.0 7.0 7.0 1.0 1 x # 1.0 2.0

36 – 47 Mos 1.5 5.0 5.0 1.5 1 x # 1.0 2.0

48 – 59 Mos 1.5 5.0 5.0 1.5 1 x # 1.0 2.0

60 Mos+ 1.5 5.0 5.0 1.5 1 x # 1.0 2.0

* Capped at 1.0 or 1.5 points**Past year; capped at 2.0 points

UPDATED PAS FOR CHILDREN UNDER 6Algorithm & Weights – Services/Treatments









7. Questions34


UPDATED PAS FOR CHILDREN UNDER 6Maintenance of Effort

AHCCCS’ intent is to maintain the existing eligibility standard, as defined in federal law

Individual customer outcomes can vary between the current PAS and revised draft tool

Pilot study results were analyzed to identify any program level impact. Findings for the updated PAS: Increase in eligibility by score for younger children, particularly

under 12 months of age Decrease in eligibility by score for children 36 – 47 months Slight increase in eligibility by score for children 48 months

and older The increase in eligibility for younger children will offset the

effect to the 36-month old group over time


The impact at the program level on eligibility and financial impact should be neutral

PHPG projected expenditures in year 1 would be 0.17 percent lower than would have occurred under the current PAS. Allowing for margin-of-error, this could mean a slight drop, increase or no change

Note: There will not be any program-wide reassessment of currently-eligible customers using the revised tool

Currently-eligible customers will not be reassessed using the revised tool unless they otherwise would have been reassessed using the current tool

UPDATED PAS FOR CHILDREN UNDER 6Maintenance of Effort

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