Medicaid commonly uses functional assessments to determine eligibility for services as well as the type and amount of services a person needs. These are usually community-based services that help people live at home, rather moving to institutions like nursing homes — an important issue considering the high risk of COVID-19 in congregate and institutional settings. To minimize risks, a number of states have extended current services and switched from face-to-face assessments to remote assessments by phone or video for people requesting new services. This shift makes assessments safer, but may lead to a loss of information compared to in-person interviews. States need to take extra steps to make sure that people get all the services they need even if remote assessments miss important data.
Phone assessments may miss communication barriers
Remote assessments rely on how well someone can understand and communicate via the phone. Assessment questions often reflect a bias toward English language and the dominant culture. Phone communication limits visual context that may make these biases worse. For example, telephonic interviews may not be sensitive enough to accurately measure chronic pain, which shows up differently in communities of color and may be easier to see face-to-face. Some evidence also suggests communities of color respond differently in telephone interviews, which might skew the results.
Telephone conversations also present added challenges for people with cognitive impairments, hearing or speech impairments, or other difficulties communicating. Telephone-based cognitive screens can help flag people for further assessment, but lack the sensitivity and specificity to definitively diagnose cognitive impairment, particularly the subtleties of picking up mild cognitive impairment. Remote assessments can measure some forms of cognitive function, like memory, but not others, like spatial or visual awareness. If assessors do not adequately capture a person’s cognitive function, that could also skew results for the rest of the functional assessment.
Any of these potential problems with telephonic or other remote interviews could mean some people might not get all the services they need.
In-person assessment observations often add insights
Remote assessments may also miss valuable data about a person’s need for physical help with daily activities. Many state assessments were designed as in-person tools with an observational component, even if it is just notes on the visit and the living space. For example, an assessor may watch a person doing basic kitchen activities, like opening a jar or carrying a plate to the table. A remote assessment, in contrast, can only ask the person if they need help with an activity, like cooking. Maybe someone is too proud to admit they need help toileting, or forgets to mention they sometimes forget their medications. Self-reported verbal responses may miss key details that would otherwise help determine whether a person needs help with activities of daily living, and maybe if they even qualify for services.
In-person assessments allow assessors to note context and visual cues particularly important for measuring cognitive function. These cues are lost by telephone. Video interviews could include observation, but raise other problems due to limited access to the internet or other necessary technology. Telephone screenings also introduce new challenges, like background noise that can make it hard to hear.
Assessments specifically designed for telephone can compensate for some — but not all — of these disadvantages. On some topics, such as substance use, people may even be more forthright over the phone. But the majority of assessments are not designed for phone interviews. Unfortunately, state assessments designed for in-person interviews will likely not produce equivalent results by phone or video.
Together, all these factors may make switching to remote assessments less likely than in-person to capture a person’s needs. This means they may not get the services they need to stay safely at home.
Strategies to get missing information
Luckily, states can help minimize these problems. For example, now more than ever, state agencies should:
- ensure that forms to request assessments have inputs, such as diagnoses or other notes, to note cognitive impairment or difficulty communicating;
- ask assessors to seek input from alternate contacts familiar with an enrollee’s situation. To do so, they should first explain in plain language what limited information the alternate contact would be asked and get the enrollee’s informed consent.
- allow assessors to rely on clinician attestations or other records to inform the assessment, such as in Rhode Island;
- allow enrollees to request 30-day reconsideration without a new assessment if they feel their needs are not being met; and
- in general, err on the side of a person needing assistance when there is uncertainty or ambiguity in the process. If there is a close call on scoring a question, choose the answer associated with higher needs. If an assessment result indicates a potential range of services or hours, authorize at the high end of the range.
Do No Harm
For now, moving to remote assessments makes sense to protect older adults and people with disabilities from potential infection. However, states need to understand the limitations of this switch and act accordingly. That means active outreach to collect more information. And it means applying more generous standards with community-based services at this time.
A remote assessment that misses key information could deny a person services they need to stay in their homes — even force them into a nursing home or other institution. That result is never acceptable. But at a time when COVID-19 has overwhelmed long-term care settings, it’s absolutely the last thing we need.
