The OKDHS area nurse, or nurse designee, determines medical eligibility for ADvantage program services based on the Long Term Care (LTC) nurse's Uniform Comprehensive Assessment Tool (UCAT) III assessment and the determination that the client has unmet care needs that require ADvantage or NF services to assure client health and safety.  ADvantage services are initiated to support the informal care that is being provided in the client's home, or, that based on the UCAT, can be expected to be provided in the client's home upon discharge of the client from a NF or hospital.  These services are not intended to take the place of regular care provided by family members and/or by significant others.  When there is an informal (not paid) system of care available in the home, ADvantage service provision will supplement the system within the limitations of ADvantage Program policy.

• (1) Definitions.  The following words and terms when used in this subchapter, shall have the following meaning, unless the context clearly indicates otherwise:
  • (A) "ADL" means the activities of daily living.  Activities of daily living are activities that reflect the client's ability to perform self-care tasks essential for sustaining health and safety such as:
    • (i) bathing,
    • (ii) eating,
    • (iii) dressing,
    • (iv) grooming,
    • (v) transferring (includes getting in and out of a tub, bed to chair, etc.),
    • (vi) mobility,
    • (vii) toileting, and
    • (viii) bowel/bladder control.
  • (B) "ADLs score in high risk range" means the client's total weighted UCAT ADL score is 10 or more which indicates the client needs some help with 5 ADLs or that the client cannot do 3 ADLs at all plus the client needs some help with 1 other ADL.
  • (C) "ADLs score at the high end of the moderate risk range" means client's total weighted UCAT ADL score is 8 or 9 which indicates the client needs help with 4 ADLs or the client cannot do 3 ADLs at all.
  • (D) "CHC" means Comprehensive Home Care.
  • (E) "Client Support high risk" means client's UCAT Client Support score is 25 which indicates in the UCAT assessor's clinical judgment, excluding from consideration existing Ryan White CARE Act, Indian Health Service, Medicaid NF, ADvantage and/or State Plan Personal Care services, very little or no support is available from informal and formal sources and the client requires additional care that is not available through Medicare, Veterans Administration, or other Federal entitlement programs.
  • (F) "Client Support moderate risk" means client's UCAT Client Support score is 15 which indicates in the UCAT assessor's clinical judgment, excluding from consideration existing Ryan White CARE Act, Indian Health Service, Medicaid NF, ADvantage and/or State Plan Personal Care services, support from informal and formal sources is available, but overall, it is inadequate, changing, fragile or otherwise problematic and the client requires additional care that is not available through Medicare, Veterans Administration, or other federal entitlement programs.
  • (G) "Cognitive Impairment" means that the person, as determined by the clinical judgment of the LTC Nurse or the AA, does not have the capability to think, reason, remember or learn required for self-care, communicating needs, directing care givers and/or using appropriate judgment for maintenance of their own health or safety.  The clinical judgment of cognitive impairment is based on MSQ performance in combination with a more general evaluation of cognitive function from interaction with the person during the UCAT assessment.
  • (H) "Developmental Disability" means a severe, chronic disability of an individual that:
    • (i) is attributable to a mental or physical impairment or combination of mental and physical impairments;
    • (ii) is manifested before the individual attains age 22;(iii) is likely to continue indefinitely;
    • (iii) results in substantial functional limitations in three or more of the following areas of major life activity:
      • (I) self-care;
      • (II) learning;
      • (III) mobility;
      • (IV) self-direction;
      • (V) capacity for independent living; and
      • (VI) economic self-sufficiency; and
    • (v) reflects the individual=s need for a combination and sequence of special, interdisciplinary, or generic services, supports, or other assistance that is of lifelong or extended duration and is individually planned and coordinated.
  • (I) "Environment high risk" means client's UCAT Environment score is 25 which indicates in the UCAT assessor's clinical judgment, the physical environment is strongly negative or hazardous.
  • (J) "Environment moderate risk" means client's UCAT Environment score is 15 which indicates in the UCAT assessor's clinical judgment, many aspects of the physical environment are substandard or hazardous.
  • (K) "Health Assessment high risk" means client's UCAT health assessment score is 25 which indicates in the UCAT assessor's clinical judgment, the client has one or more chronic health conditions, whose symptoms are rapidly deteriorating, uncontrolled, or not well controlled and requiring a high frequency or intensity of medical care/oversight to bring under control and whose functional capacity is so limited as to require full time assistance or care performed daily, by, or under the supervision of professional personnel and has multiple unmet needs for services available only through the ADvantage program or a Nursing Facility (NF) and requires NF placement immediately if these needs cannot be met by other means.
  • (L) "Health Assessment low risk" means client's health assessment score is 5 which indicates, in the UCAT assessor's clinical judgment, the client has one or more chronic, stable, health conditions, whose symptoms are controlled or nearly controlled, which benefit from available, or usually available, medical treatment or corrective measures, and may have an unmet need for a service available only through the ADvantage program or a Nursing Facility (NF) but is not likely to enter a NF if these needs are not met.
  • (M) "Health Assessment moderate risk" means client's UCAT Health Assessment score is 15 which indicates in the UCAT assessor's clinical judgment, the client has one or more chronic changing health conditions, whose symptoms are fragile or worsening and require medical care/oversight, to bring under control or to maintain in a stable, controlled state and has multiple unmet needs for services available only through the ADvantage program or a Nursing Facility (NF) and is likely to enter a NF if these needs are not met.
  • (N) "IADL" means the instrumental activities of daily living.
  • (O) "IADLs score in high risk range" means client's total weighted UCAT IADL score is 12 or more which indicates the client needs some help with 6 IADLs or cannot do 4 IADLs at all.
  • (P) "Instrumental activities of daily living" means those activities that reflect the client's ability to perform household chores and tasks within the community essential for sustaining health and safety such as:
    • (i) shopping,
    • (ii) cooking,
    • (iii) cleaning,
    • (iv) managing money,
    • (v) using a telephone,
    • (vi) doing laundry,
    • (vii) taking medication, and
    • (viii) accessing transportation.
  • (Q) "Mental Retardation" means that the person has, as determined by a PASRR level II evaluation, substantial limitations in functional ability due to significantly sub-average intellectual functioning related to an event occurring before the age of 18.
  • (R) "MSQ" means the mental status questionnaire.
  • (S) "MSQ score in high risk range" means the client's total weighted UCAT MSQ score is 12 or more which indicates a severe orientation-memory-concentration impairment, or a severe memory impairment.
  • (T) "MSQ score at the high end of the moderate risk range" means the client's total weighted UCAT MSQ score is (10) or (11) which indicates an orientation-memory-concentration impairment, or a significant memory impairment.
  • (U) "Nutrition high risk" means a total weighted UCAT Nutrition score is 12 or more which indicates the client has significant eating difficulties combined with poor appetite, weight loss, and/or special diet requirements.
  • (V) "Progressive degenerative disease process that responds to treatment" means a process such as, but not limited to, Multiple Sclerosis (MS), Parkinson's Disease, Human Immunodeficiency Virus (HIV), or Acquired Immunodeficiency Syndrome (AIDS), that, untreated, systematically impairs normal body function which leads to acute illness and/or disability but that reacts positively to a medically prescribed treatment intervention (usually medication) which arrests or significantly delays the destructive action of the process.
  • (W) "Social Resources high risk" means a total weighted UCAT Social Resources score is 15 or more, which indicates the client lives alone, combined with none or very few social contacts and no supports in times of need.
• (2) Minimum UCAT criteria.  The minimum UCAT criteria for NF level of care criteria are:
  • (A) The UCAT documents need for assistance to sustain health and safety as demonstrated by:
    • (i) either the ADLs or MSQ score is in the high risk range; or
    • (ii) any combination of two or more of the following:
      • (I) ADLs score is at the high end of moderate risk range; or,
      • (II) MSQ score is at the high end of moderate risk range; or,
      • (III) IADLs score is in the high risk range; or,
      • (IV) Nutrition score is in the high risk range; or,
      • (V) Health Assessment is in the moderate risk range, and, in addition;
  • (B) The UCAT documents absence of support or adequate environment to meet the needs to sustain health and safety as demonstrated by:
    • (i) Client Support is moderate risk; or,
    • (ii) Environment is high risk; or,
    • (iii) Environment is moderate risk and Social Resources is in the high risk range; or, regardless of whether criteria under (A) of need and (B) of absence of support are met;
  • (C) The UCAT documents that:
    • (i) the client has a clinically documented progressive degenerative disease process that will produce health deterioration to an extent that the person will meet OAC 317:35-17-2(2)(A) criteria if untreated; and\
    • (ii) the client previously has required Hospital or NF level of care services for treatment related to the condition; and
    • (iii) a medically prescribed treatment regimen exists that will significantly arrest or delay the disease process; and
    • (iv) only by means of ADvantage Program eligibility will the individual have access to the required treatment regimen to arrest or delay the disease process.
• (3) NF Level of Care Services.  To be eligible for NF level of care services, meeting the minimum UCAT criteria demonstrates the individual must:
  • (A) require a treatment plan involving the planning and administration of services that require the skills of licensed or otherwise certified technical or professional personnel, and are provided directly or under the supervision of such personnel;
  • (B) have a physical impairment or combination of physical, mental and/or functional impairments;
  • (C) require professional nursing supervision (medication, hygiene and/or dietary assistance);
  • (D) lack the ability to adequately and appropriately care for self or communicate needs to others;
  • (E) require medical care and treatment in order to minimize physical health regression or deterioration;
  • (F) require care that is not available through family and friends, Medicare, Veterans Administration, or other federal entitlement program with the exception of Indian Health Services; and
  • (G) require care that cannot be met through Medicaid State Plan Services, including Personal Care, if financially eligible.