Section 240.715  Determination of Need

 

a)         To be eligible to receive CCP services, a participant shall exhibit a need for nursing facility, supportive living program, or home and community-based services.  The Determination of Need assessment tool or any successor assessment tool authorized by the Department specifies the factors that together, determine the participant's need for long term care or home and community-based services.

 

b)         The need for long term care is based upon the determined need for a continuum of in-home and community-based services to prevent inappropriate or premature placement in a nursing facility.

 

c)         The extent and degree of a participant's need for long term care shall be determined on the basis of impaired cognitive and functional status as well as the available physical/environmental supports provided to the participant by family, friends or others in the community.

 

d)         The Determination of Need assessment tool consists of two parts:

 

1)         The Mini-Mental State Examination (Folstein, Folstein and McHugh, 1975, no later editions or amendments included) measures cognitive functioning of the participant.

 

A)        The participant who receives a score of 21 or higher shall be considered cognitively intact and zero points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool.

 

B)        The participant who receives a score of 20 or less or who has been diagnosed by a physician or psychiatrist as having dementia, Alzheimer's disease, or organic brain syndrome shall be considered cognitively impaired and ten points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool.

 

C)        Ten additional points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool for the participant who meets the following three criteria:

 

i)          Participant has been adjudicated disabled or incompetent by a Probate Court judge or judge assigned to render a decision on such matters in a court of competent jurisdiction; 

 

ii)         a physician or psychiatrist licensed by the State of Illinois has certified that, in their professional judgement, the participant suffers from Alzheimer's disease, organic brain syndrome, or dementia; and

 

iii)        a physician or psychiatrist licensed by the State of Illinois has certified that, in their professional judgement, the participant requires 24-hour home and community-based services to remain in the home.

 

2)         The Determination of Need assessment tool measures the participant's ability to perform the following activities of daily living (ADLs) and instrumental activities of daily living (IADLs):

 

A)        Activities of Daily Living

 

i)          Eating

 

ii)         Bathing

 

iii)        Grooming

 

iv)        Dressing

 

v)         Transferring

 

vi)        Incontinence

 

B)        Instrumental Activities of Daily Living

 

i)          Preparing meals

 

ii)         Being alone

 

iii)        Telephoning

 

iv)        Managing money

 

v)         Routine health

 

vi)        Special health

 

vii)       Outside home

 

viii)      Laundry

 

ix)        Housework

 

e)         The Determination of Need assessment scale includes the six ADLs and nine IADLs identified. Each function is scored in two parts:  Part A – Level of Impairment, and Part B – Unmet Need for Care.

 

1)         Part A − Level of Impairment, of the Determination of Need assessment tool measures the ability of the participant to perform each ADL and IADL function.  A scoring range of zero through three indicates the degree of impairment of the participant in the performance of ADLs and IADLs.

 

A)        A score of zero for any function indicates that the participant performs or can perform all essential components of the activity, with or without an existing assistive device, such that:

 

i)          no significant impairment of function remains;

 

ii)         activity is not required by the participant (routine health and special health only);

 

iii)        the participant may benefit from but does not require supervision or physical assistance.

 

B)        A score of one for any function indicates that the participant performs or can perform most essential components of the activity, with or without an existing assistive device, but some impairment of function remains such that the participant requires some supervision or physical assistance to accomplish some or all components of the activity.  This includes the participant who:

 

i)          experiences minor, intermittent fatigue in performing the activity;

 

ii)         takes longer time to accomplish than an unimpaired person requires; or

 

iii)        must perform the activity more frequently than an unimpaired person.

 

C)        A score of two for any function indicates that the participant cannot perform most of the essential components of the activity, even with an existing assistive device, and requires a great deal of assistance or supervision to accomplish the activity.  This includes the participant who:

 

i)          experiences frequent fatigue in performing the activity;

 

ii)         takes an excessive amount of time to perform the activity; or

 

iii)        must perform the activity much more frequently than an unimpaired person.

 

D)        A score of three for any function indicates that the participant cannot perform the activity and requires someone to perform the task, although the participant may be able to assist in small ways, or requires constant supervision.

 

2)         Part B, Unmet Need for Care, of the Determination of Need assessment tool measures the need of the participant for assistance/performance/supervision for each ADL and IADL function that is not being met by non-CCP resources in the community (e.g., family, friends, local services).

 

A)        A score of zero for any function indicates that there is no impairment, or that the participant's need for assistance is met to the extent that the participant is at no risk to health or safety if additional assistance is not acquired, or that additional assistance will not benefit the participant, or that the participant's needs are being met by non-CCP resources and, therefore, the participant has no need for assistance.

 

B)        A score of one for any function indicates that the participant's need for assistance is met most of the time, but the participant's health and safety are at minimal risk if additional assistance is not acquired.

 

C)        A score of two for any function indicates that the participant's need for assistance is not met most of the time, and the participant's health and safety are at moderate risk if additional assistance is not acquired.

 

D)        A score of three for any function indicates that the participant's need for assistance is rarely, or never, met and the participant's health and safety are at severe risk, which would require acute medical intervention, if additional assistance is not acquired.

 

(Source:  Amended at 48 Ill. Reg. 11053, effective July 16, 2024)