C2F - Internal Action Plan: Nursing Assessment
The Division of Developmental Disabilities is working with the Northern Arizona University Centers for Excellence in Developmental Disabilities (UCEDD) to improve how it assesses Nursing services. This work includes review and revision of Division Medical Policy Manual Chapter 1240-G. The revised policy was posted for public comment from March 24, 2021 to April 21, 2021.
DDD and NAU-UCEDD also created a new tool for assessing Nursing services. Currently, nursing services are determined based on the Nurse’s judgement. The new tool ensures Inter-Rater Reliability. This means that two Nurses will assess similar hours for the same person. The tool uses a scoring system for both service hours needed and modifiers. The scoring system is based on best practice criteria. This tool is called the Hourly Nursing Assessment Tool (H-NAT). The H-NAT will allow Division Nurses to accurately assess the appropriate level of nursing services for each member. Division Nurses will start using the H-NAT on August 1, 2021.
The use of the H-NAT may change the number of nursing services hours some members receive. Any decrease in nursing hours will be submitted to the District Nursing Manager for approval. Any service hour reduction will happen over a 90 day period. DDD will mail a Notice of Adverse Benefit Determination (NOA) within 10 days of a service reduction if the member or family disagrees. The member has the right to appeal the decrease if they do not agree. The member will continue to receive the current number of service hours until the appeal is resolved. If the appeal is denied the member may be responsible for the cost of the continued services.
Frequently Asked Questions
Q: What is the Nursing Assessment CAP?
A: The Nursing Assessment Corrective Action Plan (CAP) is a contract action taken by AHCCCS against DDD. AHCCCS identified deficiencies related to the Division’s Nursing assessment process. The Division created a tool, the Hourly Nursing Assessment Tool (H-NAT), to address these deficiencies.
Q: What is the Hourly Nursing Assessment Tool (H-NAT)?
A: The H-NAT was developed in collaboration with Northern Arizona University (NAU). It helps Division Nurses identify the skilled nursing a member needs. The tool identifies the amount of time skilled nursing services should take. It does allow the Division Nurse to use clinical judgement based on the specific member’s needs. This includes available natural supports and the member's willingness to accept help. The tool has been tested to ensure consistency and reliability in all districts.
Q: Who is NAU and what are they assisting with regarding the Nursing Assessment CAP?
A: Northern Arizona University (NAU) is one of Arizona's University Centers for Excellence in Developmental Disabilities (UCEDD). They serve as a resource related to the needs of people with developmental disabilities. The Division contracted with NAU to conduct research, develop training, and ensure the assessment met best practices.
Q: Who does the H-NAT impact?
A: The H-NAT will impact members who receive skilled nursing services and vendors who provide those services.
Q: How will the H-NAT affect my skilled nursing hours?
A: A District Nurse will use the H-NAT and their clinical judgement to assess service needs. This may result in fewer or additional hours being assessed. Any changes will be communicated to the member/member’s family and discussed with their planning team.
Q: What if I disagree with the level of services assessed?
A: The District Nurse will discuss the assessment with the member and their planning team. They will explain the assessment and try to reach an agreement. A Notice of Adverse Benefit Determination will be given to the member if they cannot reach an agreement. The member can then appeal the decision with the Division.
Q: Who will use the H-NAT?
A: DDD District Nurses will use the H-NAT to provide consistent and reliable skilled nursing hours assessment.
Q: Will vendors be trained on the H-NAT?
A: No, this is an internal tool used only by DDD District Nurses.
Q: Will vendors use the H-NAT?
A: No, this is an internal tool used only by DDD District Nurses.
Q: How often will an H-NAT be done, and can members or families request one be completed?
A: Once implemented, the H-NAT will be completed for members in conjunction with the nursing assessment when their quarterly assessment is due. Thereafter, the Nursing Assessment and H-NAT will be reviewed and updated as needed due to changes in skilled nursing needs, or at least quarterly. The Nursing assessment and H-NAT can be completed with any change in condition or at the request of the SC, Member, or responsible person.
Q: What skilled services are included in the H-NAT?
A: Skilled services included in the H-NAT are those found on the Division Medical Policy Manual 1240-G Nursing Matrix. Please review Exhibit 1240 G-1, Skilled Nursing matrix, for a list of skilled nursing services. Additional items on the H-NAT include a general head-to-toe assessment and modifiers (e.g., behavior, communication, risk).
Q: How will the H-NAT be used to determine skilled nursing hours?
A: The H-NAT will be used as part of the assessment process. Using a series of questions, the District Nurse will use the tool and their clinical judgement to assess for service needs. An estimated range of skilled nursing hours will be developed based on that information.
Q: Why are certain issues like mobility not listed in the H-NAT?
A: Mobility by itself is not a skilled need. There is a space in the tool to document this. The H-NAT is an internal tool used only by DDD Nurses to determine skilled nursing hours for members. It is not a replacement for clinical judgement.
Q: How are Modifiers being scored?
A: Modifiers are not scored, they are used to add additional time to the H-NAT. Nurses rely on documentation on the Nursing Assessment, their clinical judgement, and the time ranges that correspond with each of the modifiers to come up with modifier time estimates.