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Transcript of 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
THE PACIFIC HEALTH POLICY GROUP
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. Questions3
UPDATED PAS FOR CHILDREN UNDER 6Topics
THE PACIFIC HEALTH POLICY GROUP
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
THE PACIFIC HEALTH POLICY GROUP
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
THE PACIFIC HEALTH POLICY GROUP
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. Questions6
UPDATED PAS FOR CHILDREN UNDER 6Topics
THE PACIFIC HEALTH POLICY GROUP
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
THE PACIFIC HEALTH POLICY GROUP
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. Questions8
UPDATED PAS FOR CHILDREN UNDER 6Topics
THE PACIFIC HEALTH POLICY GROUP
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 PACIFIC HEALTH POLICY GROUP
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?
THE PACIFIC HEALTH POLICY GROUP
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. Questions11
UPDATED PAS FOR CHILDREN UNDER 6Topics
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
THE PACIFIC HEALTH POLICY GROUP 13
# 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
THE PACIFIC HEALTH POLICY GROUP 14
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 15
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 16
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 17
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 18
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 19
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 20
# 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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 21
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 22
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 23
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 24
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 25
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP 26
# Milestone Applies to:
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
UPDATED PAS FOR CHILDREN UNDER 6Developmental Milestones
THE PACIFIC HEALTH POLICY GROUP
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. Questions27
UPDATED PAS FOR CHILDREN UNDER 6Topics
THE PACIFIC HEALTH POLICY GROUP
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
THE PACIFIC HEALTH POLICY GROUP
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
THE PACIFIC HEALTH POLICY GROUP
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
THE PACIFIC HEALTH POLICY GROUP
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
UPDATED PAS FOR CHILDREN UNDER 6Algorithm & Weights – Detailed Criteria
THE PACIFIC HEALTH POLICY GROUP
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
UPDATED PAS FOR CHILDREN UNDER 6Algorithm & Weights – Detailed Criteria
THE PACIFIC HEALTH POLICY GROUP 33
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
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. Questions34
THE PACIFIC HEALTH POLICY GROUP 35
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 PACIFIC HEALTH POLICY GROUP 36
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