212.100 An Overview of Resource Utilization Groups (RUGs) Thie ARCholces Waiver provides beneficiaries with a monthly allocation of attendant care hours to be used at the beneficiary's discretion throughout the month. The number of attendant care hours approved for each beneficiary is based on the results of that beneficiary's most recent assessment using the ArPath Assessment Tool.
The ArPath Assessment Tool uses a software program that includes an algorithm to evaluate certain responses within an extensive questionnaire to determine whether the beneficiary meets the functional eligibility criteria to participate In the waiver program. The ArPath Assessment Tool then uses another algorithm to evaluate other responses to determine which Resource Utilization Group (RUG) reflects the beneficiary's functional abilities. A RUG Is a tier group consisting of individuals with similar functional abilities.
In 2013, attendant care services were detennined based on an RN's discretionary interpretation of a beneficiary's responses to the ArPath Assessment Tool's questionnaire. Between 2013 and January 1,2016, when the ARCholces program was implemented, DAAS recorded beneficiary RUG placement and the number of paid attendant care hours utilized by beneficiaries each month in order to detemiine the type and amount of resources that beneficiaries with similar functional abilities were used in a given month.
While the reality of living with a disease or condition can vary greatly even among individuals with the same diagnosis, a RUG placement allows DAABHS to better predict the type and extent of care that an individual needs. The purpose of transitioning to a RUG-based care allocation system is to provide more predictable and objective outcomes that better reflect the reality of a beneficiary's needs by organizing the allocation around functional ability.
As of January 1, 2016, the allocation of attendant care hours became based on which RUG the beneficiary is placed in by the ArPath Assessment Tool. The specific number of attendant care hours assigned to a particular RUG was determined by considering an average of the number of hours used by beneficiaries placed in that RUG prior to the implementation of the ARCholces program. The following chart shows the number of hours assigned to each RUG.
RUGCategory | RUG | Monthly Hours |
Special Rehab | RBO | 157 |
RA2 | 97 |
RA1 | 55 |
Extensive Care | SE3 | 352 |
SE2 | 201 |
SE1 | 153 |
Special Care | SSB | 161 |
SSA | 112 |
Clinically Complex | ceo | 143 |
CBO | 94 |
CA2 | 69 |
CA1 | 36 |
Impaired Cognition | ISO | 116 |
IA2 | 81 |
IA1 | 38 |
Behavioral Problems | BBO | 118 |
BA2 | 62 |
BA1 | 30 |
Reduced Physical Function | PDO | 137 |
PCO | 99 |
PBO | 81 |
PA2 | 53 |
PA1 | 28 |
RUG Requirements
The ArPath Assessment Tool evaluates the assessment responses using an algorithm, which is basically a "rule book" for the software. This particular rulebook is divided into chapters, known as screeners, and each screener is responsible for evaluating a small portion of the assessment responses in order to produce a numerical score. Below is a list of the screeners and the possible scores:
Screener | Possible Scores |
Activities of Daily Living (ADL) | 4-18 |
instrumental Activities of Daily Living (lADL) | 0-3 |
Rehab | 0-1 |
Behavior Problems | 0-1 |
Extensive Care | 0-1 |
Special Care | 0-1 |
Clinically Complex | 0-1 |
Cognitive Impairment | 0-1 |
Cumulative | 0-5 |
Each RUG requires a different combination of screener scores in order for a beneficiary to be placed in that RUG. The ArPath Assessment Tool utilizes the criteria for each RUG in the exact order that they are listed in the above chart and it places the beneficiary in the first RUG on the list whose criteria are satisfied by the assessment responses.
The following is a description of the screener scores required for each Special Rehab RUG.
A. RBO requires a Rehab screener score of 1 and an ADL score of at least 11.B. RA2 requires a Rehab screener score of 1, an lADL score of at least 2, and an ADL score of no more than 10.C. RA1 requires a Rehab screener score of 1, an lADL score of 1 or 0, and an ADL score of no more than 10. The following is a description of the screener scores required for each Extensive Care RUG.
A. SE3 requires a Cumulative screener score of at least 4, an Extensive Care screener score of 1, and an ADL score of at least 7.B. SE2 requires a Cumulative screener score of either 2 or 3, an Extensive Care screener score of 1, and an ADL score of at least 7.C. SE1 requires a Cumulative screener score of no more than 1, an Extensive Care screener score of 1, and an ADL score of at least 7. The following is a description of the screener scores required for each Special Care RUG.
A. SSB requires an ADL score of at least 14 and a score of 1 for either the Extensive Care screener or the Special Care screener.B. SSA has two possible combinations: 1. An Extensive Care screener score of 1 with and ADL score of no more than 6, or2. An ADL score within the range of 7-13 and a score of 1 for either the Extensive Care screener or the Special Care screener. The following Is a description of the screener scores required for each Clinically Complex RUG.
A. ceo requires an ADL score of at least 11 and a score of 1 for either the Clinically Complex screener or the Special Care screener.B. CBO requires an ADL score within the range of 6-10 and a score of 1 for either the Clinically Complex screener or the Special Care screener.C. CA2 requires and ADL score no higher than 5, an lADL score of at least 1, and a score of 1 for either the Clinically Complex screener or the Special Care screener.D. CA1 requires and ADL score no higher than 5, an lADL score of 0, and a score of 1 for either the Clinically Complex screener or the Special Care screener. The following is a description of the screener scores required for each Impaired Cognition RUG.
A. IBO requires a Cognitive Impairment screener score of 1 and an ADL score within the range of 6-10.B. 1A2 requires a Cognitive Impairment screener score of 1, an lADL score of at least 1, and an ADL score of no more than 5.C. IA1 requires a Cognitive Impairment screener score of 1, an lADL score of 0, and an ADL score of no more than 5. The following Is a description of the screener scores required for each Behavioral Problems RUG.
A. BBO requires a Behavior Problems screener score of 1 and an ADL score within the range of 6-10.B. BA2 requires a Behavior Problems screener score of 1, an lADL score of at least 1, and an ADL score of no more than 5.C. BA1 requires a Behavior Problems screener score of 1, an lADL score of 0, and an ADL score of no more than 5. The following is a description of the screener scores required for each Reduced Physical Function RUG.
A. PDO requires a Rehab screener score of 0 and an ADL score of at least 11.B. PCO requires a Rehab screener score of 0 and an ADL score of 9 or 10.C. PBO requires a Rehab screener score of 0 and an ADL score of 6, 7, or 8.D. PA2 requires a Rehab screener score of 0, an lADL score of at least 1, and an ADL score of no more than 5.E. PA1 requires a Rehab screener score of 0, an lADL score of 0, and an ADL score of no more than 5. Screener Requirements
Activities of Daily Living f ADL)
A beneficiary's ADL score ranges from 4 to 18. It is based on the collective score among responses to the 5 items in the assessment that are listed below. Only 4 of the 5 responses will add to the overall ADL score because the response to Mode of nutritional intake may override the response to Eating.
E. Mode of nutritional intake Bed mobility, Transfer toilet, and Toilet use are all scored in the following way:
A. Independent gets 1 point,B. Independent, set up help only gets 1 point,C. Supervision gets 1 point,D. Limited assistance gets 3 points,E. Extensive assistance gets 4 points,F. Maximal assistance gets 5 points,G. Total dependence gets 5 points, and H. Activity did not occur gets 5 points Eating is scored in the following way:A. Independent gets 1 point,B. Independent, set up help only gets 1 point,C. Supervision gets 1 point,D. Limited assistance gets 2 points,E. Extensive assistance gets 3 points,F. Maximal assistance gets 3 points,G. Total dependence gets 3 points, andH. Activity did not occur gets 3 points. However, 3 points will be added to the ADL score, and the Eating score will be ovenidden if the response to Mode of nutritional intake is any of the following:
A. Combined oral and parenteral or tube feeding,B. Nasogastric tube feeding only,C. Abdominal feeding tube, orD. Parenteral feeding tube onlyE. Instnjmental Activities of Daily Living (lADL) A beneficiary's lADL score ranges from 0 to 3. It is based on the collective score among the responses to the following items in the assessment: A. Meal preparation-perfomiance.B. Managing medication-performance, orC. Phone use-performance. The responses to each item are scored in the following way.
A. Independent gets 0 points.B. Independent, set up help only gets 0 points.C. Supervision gets 0 points.D. Limited assistance gets 0 points.E. Extensive assistance gets 0 points.F. Maximal assistance gets 1 pointG. Total dependence gets 1 point.H. Activity did not occur gets 1 point. Rehab
A beneficiary's Rehab screener score is 0 by default, but it equals 1 if during the week prior to the assessment the beneficiary spends a total of at least 120 minutes in any combination of the following types of therapy:
A. Speech-language pathology,B. Occupational therapy, orC. Physical therapy. Behavior Problems
A beneficiary's Behavior Problems score is 0 by default, but it equals 1 if the beneficiary has exhibited any of the following at any time within 3 days of the assessment:
D. Socially inappropriate or disruptive behavior,G. Hallucinations. Extensive Care A beneficiary's Extensive Care screener score is 0 by default, but It equals 1 if the response to Mode of nutritional Intake Is either Abdominal feeding tube or Parenteral feeding tube only. It will also equal 1 if the assessment records that any of the following treatments have been utilized within 3 days of the assessment:
D. Ventilator or respirator. Special Care
A beneficiary's Special Care screener score Is 0 by default, but It equals 1 if the assessment records that Radiation therapy has been utilized within 3 days of the assessment or any of the following combinations of responses are logged In the assessment:
A. A turnlng/reposltioning program has been utilized within 3 days of the assessment and the response to Most severe pressure ulcer Is either:1. Deep craters In the skin or2. Breaks in the skin exposing muscle or bone;B. Aphasia has been exhibited within 3 days of the assessment and the Mode of nutritional intake Is either: 1. Nasogastric tube feeding or2. Combined oral and parenteral or tube feeding;C. Wound care has been perfonned within 3 days of the assessment and the response to either of the following items is yes:1. Major skin problems orD. Fever and Vomiting are exhibited within 3 days of the assessment;E. Fever Is exhibited within 3 days of the assessment and the response to Weight loss of 5% Is yes;F. Fever Is exhibited within 3 days of the assessment and the response to Mode of nutritional Intake Is either: 1. Nasogastric tube feeding or2. Combined oral and parenteral or tube feeding;G. Fever is exhibited within 3 days of the assessment and the response to Pneumonia is any of the following: 1. Primary diagnosis for current stay;2. Diagnosis present, receiving active treatment; or3. Diagnosis present, monitored but no active treatment;H. Fever is exhibited within 3 days of the assessment and the response to Dehydration is yes; orI. A beneficiary's ADL score is at least 10 and the response to either Multiple sclerosis or Quadriplegia is any of the following:1. Primary diagnosis for current stay;2. Diagnosis present, receiving active treatment; or3. Diagnosis present, monitored but no active treatment. Clinically Complex
A beneficiary's Clinically Complex screener score is 0 by default, but it equals 1 if any of the following Is recorded during the assessment:
A. Mode of nutritional intake is either Nasogastric tube feeding or Combined oral and parenteral or tube feeding;B. The response to Cognitive skills for daily decision making is No discemable consciousness, coma and the response to any of the following is either Total dependence or Activity did not occur:C. Any form of Sepsis is recorded in the Other Diseases section of the assessment;D. The response to Dehydration is yes;E. The beneficiary's ADL score is at least 10 and the response to Hemiplegia is any of the following: 1. Primary diagnosis for current stay;2. Diagnosis present, receiving active treatment; or3. Diagnosis present, monitored but no active treatment;F. Gl or GU bleeding has been exhibited in the 3 days prior to the assessment;G. The response to Pneumonia is any of the following:1. Primary diagnosis for current stay;2. Diagnosis present, receiving active treatment; or3. Diagnosis present, monitored but no active treatment;H. The response to End stage disease, 6 or fewer months to live is yes;I. Chemotherapy was utilized within 3 days of the assessment;J. Dialysis was utilized within 3 days of tlie assessment;K. A transfusion occurred within 3 days of the assessment;L. Oxygen therapy was utilized within 3 days of the assessment; orM. The response to Foot problems is either Foot problems limit walking or Foot problems prevent walking. Impaired Cognition
A beneficiary's Impaired Cognition screener score is 0 by default, but it equals 1 if the score recorded on the Cognitive Performance Scale (CPS) is at least a 3.
Cumulative
A beneficiary's Cumulative screener score can range from 0 to 5. It is based on the collective score after adding the scores from the Special Care, Clinically Complex, and Impaired Cognition screeners. An additional point may be added if either of the following occurs:
A. The response to Mode of nutritional intake is Parenteral feeding only orB. IV medication is utilized within 3 days of the assessment.