Free Family Support Program Functional Screen - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20851 (Rev. 08/2008)

STATE OF WISCONSIN

FAMILY SUPPORT PROGRAM FUNCTIONAL SCREEN
This screen is designed to help the reviewer determine whether or not a child has a severe disability by the statutory definition used for the Family Support Program. The presence of a severe disability in a child is the first step in determining whether or not a family is eligible for the Family Support Program. Other criteria for family eligibility are discussed in the Family Support Program Guidelines and Procedures, and are reviewed separately. Before using this screen, read the document thoroughly and become familiar with the process of review. Follow screen directions carefully. Your responses to the questions should be based on information from a variety of sources. In addition to the reviewer's own observations and assessment, use supporting documentation including: medical records, M-Team reports, formal testing results, clinical reports, etc. Complete at initial eligibility determination for Family Support Program and at any time when the child's condition changes.
Name - Child Birthdate (mm / dd / yyyy)

Name - Agency

Screening Date

Name - Reviewer

SIGNATURE - Reviewer

I.

PRE-SCREEN REVIEW If a child's condition has already been reviewed and the child is determined to have a severe disability* under certain other programs, that determination may be used and the reviewer need not proceed with this functional screen. All children who are reviewed in this way are expected to meet the criteria in this screen regardless of whether or not this screen is used. Check the program for which the child is currently determined to be eligible: Community Integration Program - State Institutions, (CIP 1A) Community Integration Program - Nursing Homes, (CIP 1B) Community Options Program (COP), Level II only Other Program (name) ___________________________________________________, child meets the requirements of this screen. The eligibility criteria for this program are included in the county's annual Family Support Program plan. If any of the above are checked, stop here. There is no need to complete the remainder of the form. The child has been determined to have a severe disability based on the criteria in this screen. Do not use eligibility for the following as automatic determinants of a severe disability: · · · · Supplemental Security Income Program (SSI) Program for Children with Special Health Care Needs (PCSHCN) Birth to 3 Program Katie Beckett Program

*

See statutory definition of "disabled" in FSP Guidelines, Section 4.40, C.

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20851 (Rev. 08/2008)

STATE OF WISCONSIN

II. SCREENING FOR SEVERE DISABILITY All of the following conditions, A through C, must be met. A. The child has a severe physical, emotional or mental impairment which is diagnosed medically, behaviorally or psychologically. The disability is likely to continue indefinitely. The reviewer should examine the child's current functional abilities that are expected to persist for at least one year. Medical needs which do not result in ongoing substantial functional impairments that continue for at least one year or which change significantly with medical interventions do not meet this criterion even if the diagnosis is severe. If a child has a degenerative condition, eligibility begins when the child's functional limitations are substantial, not necessarily when a diagnosis of the condition is made. The disability results in substantial* functional limitations in three or more areas of major life activity. To assess substantial functional limitations of children at different ages and expected levels of development, determine the chronological age of the child and attach the screen that corresponds to the child's age. When reviewing for severe emotional or psychological disturbances, use only Screen G, regardless of the child's age. *The term "substantial" means a severe impairment which restricts the child's ability to engage in everyday activities or perform daily functions independently within a reasonable range in the home and community. This means that parents or others must provide considerable assistance to the child to complete daily functions. The help that the child needs is well outside the bounds that would be expected for the child's age, or the help requires parents or others to perform nursing skills to assist the child. The reviewer should not rely solely on individual testing scores to satisfy the substantial functional impairment requirement. Testing may show that a child has a significant delay in a certain area. However, the delay may not have an extraordinary effect on the child's ability to participate independently in most normal daily activities. In order to meet the requirement for substantial functional limitations, one of the following is checked. Child has at least 3 areas of substantial functional limitations as shown on attached Screen __________. Child has a condition which is expected to deteriorate within the year and cause substantial functional limitations in 3 or more areas. Child has a condition which requires an extraordinary amount of equipment and / or technological assistance to keep the child from being delayed in 3 or more areas.

B.

C.