1. Updating the PAS for Children Under 6 Public Hearing The Pacific Health Policy Group October 12, 2010

2. THE PACIFIC HEALTH POLICY GROUP UPDATED PAS FOR CHILDREN UNDER 6 Topics 1. Background and objectives 2. Updated PAS development steps 3. Whats changing and what isnt 4. Updated developmental milestones 5. Updated algorithm and weights 6. Maintenance of Effort 7. Questions 2

3. THE PACIFIC HEALTH POLICY GROUP 1. Background and objectives 2. Updated PAS development steps 3. Whats changing and what isnt 4. Updated developmental milestones 5. Updated algorithm and weights 6. Maintenance of Effort 7. Questions 3 UPDATED PAS FOR CHILDREN UNDER 6 Topics

4. THE PACIFIC HEALTH POLICY GROUP AHCCCS uses a comprehensive pre-admission screen (PAS) and score to determine eligibility for the ALTCS program AHCCCS was an early adopter of objective, score- based clinical eligibility criteria (becoming the national norm) Instruments should be updated periodically to reflect latest research PAS for children under age 6 last updated in 1995 Research on measuring childhood development has continued in the intervening years 4 UPDATED PAS FOR CHILDREN UNDER 6 Background

5. THE PACIFIC HEALTH POLICY GROUP Ensure that the PAS continues to properly identify children who meet the standard for eligibility (which is not changing): Immediate risk of institutionalization in an ICF/MR (regardless of actual service setting) Incorporate latest research in measurement of age- appropriate developmental milestones Replace adult-oriented independent living skill, communication and behavior items with age- appropriate developmental milestones Update measurement of Autism Spectrum Disorder- related behaviors and developmental issues 5 UPDATED PAS FOR CHILDREN UNDER 6 Objectives

6. THE PACIFIC HEALTH POLICY GROUP 1. Background and objectives 2. Updated PAS development steps 3. Whats changing and what isnt 4. Updated developmental milestones 5. Updated algorithm and weights 6. Maintenance of Effort 7. Questions 6 UPDATED PAS FOR CHILDREN UNDER 6 Topics

7. THE PACIFIC HEALTH POLICY GROUP Expert panel convened, including independent developmental pediatricians, PHPG consultants and senior AHCCCS assessors and managers Research conducted on nationally-recognized and validated studies and instruments (e.g., Ages & Stages, Vineland-II, ICAP, CDC Guidelines, MCHAT) Developmental section revised and significantly expanded Pilot study data collected over five months (770 cases) Statistical analysis performed to construct new scoring algorithm, with age-specific weights Preliminary algorithm reviewed by experts to ensure clinical soundness 7 UPDATED PAS FOR CHILDREN UNDER 6 Development Steps

8. THE PACIFIC HEALTH POLICY GROUP 1. Background and objectives 2. Updated PAS development steps 3. Whats changing and what isnt 4. Updated developmental milestones 5. Updated algorithm and weights 6. Maintenance of Effort 7. Questions 8 UPDATED PAS FOR CHILDREN UNDER 6 Topics

9. THE PACIFIC HEALTH POLICY GROUP A single PAS for all children under age 6 Greater use of developmental milestones (with new milestones added at more frequent age intervals) New variables that recognize behaviors or developmental delays related to ASD are being recognized through the scoring algorithm Use of age-appropriate developmental milestones in place of adult-oriented variables Updated weights for variables carried over from the previous PAS instruments 9 UPDATED PAS FOR CHILDREN UNDER 6 What is Changing?

10. THE PACIFIC HEALTH POLICY GROUP The PAS assessment process Medical section of PAS (scoring and weights have been updated) 40 point threshold for eligibility Use of physician review Eligibility standard: Immediate risk of institutionalization in an ICF/MR (regardless of actual service setting) 10 UPDATED PAS FOR CHILDREN UNDER 6 What is Staying the Same?

11. THE PACIFIC HEALTH POLICY GROUP 1. Background and objectives 2. Updated PAS development steps 3. Whats changing and what isnt 4. Updated developmental milestones 5. Updated algorithm and weights 6. Maintenance of Effort 7. Questions 11 UPDATED PAS FOR CHILDREN UNDER 6 Topics

12. THE PACIFIC HEALTH POLICY GROUP 12 DomainExamples Gross Motor Skills Does your child walk up stairs, using only one foot on each stair? Fine Motor Skills Does your child turn the pages of a book one at a time? Communication Does your child state their own first name or nickname? Socialization Does your child know if s/he is a boy or a girl? Daily Living Skills Does your child pull up clothing with elastic waistbands? Behaviors Does your child stare at nothing or wander with no purpose? UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestone Domains

13. THE PACIFIC HEALTH POLICY GROUP 13 #MilestoneApplies to: 1 Does your child lift their head when lying on their back? 6 months & older 2 When your child is on their tummy, does s/he straighten both arms and push their whole chest off the floor? 6 months & older 3 If you hold both hands just to balance your child, does s/he support their own weight while standing? (That is, can s/he bear weight? 6 months & older 4Does your child reach for or grasp a toy?6 months & older 5 Does your child try to pick up a crumb or Cheerio by using their thumb and all their fingers in a raking motion, even if they arent able to pick it up? (If they already pick up the crumb or Cheerio, check yes for this item.) 6 months & older 6Does your child make high-pitched squeals?6 months & older 7 Does your child show two or more emotions? (For example, laughs, cries, screams etc.) 6 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

14. THE PACIFIC HEALTH POLICY GROUP 14 #MilestoneApplies to: 8 Does your child act differently toward strangers than s/he does with you and other familiar people? (Reactions to strangers may include, for example, staring, frowning, withdrawing or crying.) 6 months & older 9 Does your child stiffen and arch their back when picked up? Reverse scoring 6 months & older 10 Does your child roll from their back to their tummy, getting both arms out from under them? 9 months & older 11 When you stand your child next to furniture or the crib rail, does s/he stand, holding onto the furniture for support 9 months & older 12 Does your child creep or move on their stomach across the floor? 9 months & older 13 Does your child sit supported (for example, in a chair with pillows etc.) for at least 1 minute? 9 months & older 14 When a loud noise occurs, does your child respond? (For example, act startled, cry or turn toward the sound.) 9 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

15. THE PACIFIC HEALTH POLICY GROUP 15 #MilestoneApplies to: 15 If you call your child when you are out of their line-of- sight, does s/he look in the direction of your voice? 9 months & older 16 Does your child make non-word sounds? (That is, babble or jabber.) 9 months & older 17 Does your child look toward you (parent or caregiver) when hearing your (parent or caregivers) voice? 9 months & older 18Does your child enjoy playing peek-a-boo/pat-a-cake?9 months & older 19Does your child feed themselves a cracker or cookie?9 months & older 20 Does your child walk around the furniture while holding on with one hand? 12 months & older 21 Does your child crawl at least 5 feet on hands and knees, without stomach touching the floor? 12 months & older 22Does your child hold a bottle or cup?12 months & older 23 Does your child move an object from one hand to the other? 12 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

16. THE PACIFIC HEALTH POLICY GROUP 16 #MilestoneApplies to: 24 Does your child pick up a small object with thumb and fingers? 12 months & older 25 Does your child coo or laugh or make other sounds of pleasure? 12 months & older 26 Does your child reach for familiar person when person holds out arms to them? 12 months & older 27 Does your child play with a doll or stuffed animal by hugging it? 12 months & older 28 Does your child suck or chew on finger foods? (For example, crackers, cookies, toast etc.) 12 months & older 29 Does your child stand up in the middle of the room by themselves and take several steps forward? 18 months & older 30Does your child climb on furniture?18 months & older 31 Does your child turn the pages of a board, cloth or paper book by himself/herself? (S/he may turn more than one page at a time.) 18 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

17. THE PACIFIC HEALTH POLICY GROUP 17 #MilestoneApplies to: 32 Without showing them how, does your child scribble back and forth when you give them a crayon (or pencil or pen)? 18 months & older 33 Does your child stack a small toy, block, cup, dish or other object on top of another one? 18 months & older 34Does your child respond to their name when you call?18 months & older 35 When playing with sounds, does your child make grunting, growling or deep-toned sounds? 18 months & older 36 Does your child say Da-da or Ma-ma or another name for parent or caregiver (including parents or caregivers first name or nickname)? 18 months & older 37 When you ask your child to point to their nose, eyes, hair, feet, ears and so forth, does your child correctly point to at least one body part? (They can point to themselves, you or a doll.) 18 months & older 38 If you point at a toy across the room, does your child look at it? 18 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

18. THE PACIFIC HEALTH POLICY GROUP 18 #MilestoneApplies to: 39 Does your child ever use their index finger to point, to indicate interest in something? 18 months & older 40Does your child ever bring objects over to you?18 months & older 41 Does your child imitate you? For example, you make a face – will your child imitate it? 18 months & older 42Does your child take an interest in other children?18 months & older 43 Does your child eat solid foods? (For example, cooked vegetables, chopped meats etc.) 18 months & older 44Does your child like being hugged or cuddled?18 months & older 45Does your child run?24 months & older 46 Does your child jump, with both feet leaving the floor at the same time? (That is, can s/he jump up?) 24 months & older 47Does your child flip light switches off and on?24 months & older 48 Does your child put up a small object in a cup and dump it out? (You may show them how.) 24 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

19. THE PACIFIC HEALTH POLICY GROUP 19 #MilestoneApplies to: 49 Does your child stack at least four small toys, blocks, cups, dishes or other objects on top of each other? 24 months & older 50 Does your child name at least three objects? (For example, bottle, dog, favorite toy etc.) 24 months & older 51 Does your child follow instructions with one action and one object? (For example, Bring me the book; Close the door etc.) 24 months & older 52 Does your child demonstrate understanding of the meaning of no, or word or gesture with the same meaning? (For example, stops current activity briefly.) 24 months & older 53 Does your child copy the activities you do, such as wipe up a spill, sweep, shave or comb hair? 24 months & older 54 Does your child play near another child, each doing different things? 24 months & older 55 Does your child hold and drink from a cup or glass? (Includes sippy cups.) 24 months & older 56Does your child look at you when you talk to them?24 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

20. THE PACIFIC HEALTH POLICY GROUP 20 #MilestoneApplies to: 57While standing, does your child throw a ball or toy?30 months & older 58 Does your child ask questions beginning with what or where? (For example, Whats that?; Where doggie go? etc.) 30 months & older 59 Does your child call themselves I or me more often than their own name? (For example, I do it more than Mary (John) do it.) 30 months & older 60 Does your child take off clothing that opens in the front (for example, a coat or sweater)? (Does not have to unbutton or unzip the clothing.) 30 months & older 61Does your child use a spoon to feed themselves?30 months & older 62 Does your child sleep at least 8 hours in a 24-hour period? 30 months & older 63 Does your child do things over and over and cant seem to stop? (Examples are rocking, hand flapping or spinning.) Reverse Scoring 30 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

21. THE PACIFIC HEALTH POLICY GROUP 21 #MilestoneApplies to: 64 Does your child destroy or damage things on purpose? Reverse Scoring 30 months & older 65 Does your child hurt themselves on purpose? Reverse Scoring 30 months & older 66 Does your child stand (balance) on one foot for about 1 second without holding onto anything? 36 months & older 67 Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) S/he may hold onto the railing or wall. 36 months & older 68 Does your child turn the pages of a book one at a time? 36 months & older 69 Does your child use simple words to describe things? (For example, dirty, pretty, big, loud etc.) 36 months & older 70 Does your child state their own first name or nickname? 36 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

22. THE PACIFIC HEALTH POLICY GROUP 22 #MilestoneApplies to: 71 Does your child follow instructions with two actions or an action and two objects? (For example, Bring me the crayons and the paper; Sit down and eat your lunch etc.) 36 months & older 72 Does your child pretend objects are something else? (For example, does your child hold a cup to their ear, pretending it is a telephone? Does s/he put a box on their head, pretending it is a hat? Does s/he use a block or small toy to stir food?) 36 months & older 73Does your child know if s/he is a boy or a girl?36 months & older 74 Does your child pull up clothing with elastic waistbands? (For example, underwear or sweatpants.) 36 months & older 75Does your child suck from a straw?36 months & older 76 Does your child cry, scream or have tantrums that last for 30 minutes or longer? Reverse Scoring 36 months & older 77 Does your child act physically aggressive? (For example, hits, kicks, bites etc.) Reverse Scoring 36 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

23. THE PACIFIC HEALTH POLICY GROUP 23 #MilestoneApplies to: 78 Does your child have eating difficulties? (For example, eats too fast or too slowly, hoards food, overeats, refuses to eat etc.) Reverse Scoring 36 months & older 79 Does your child sometimes stare at nothing or wander with no purpose? Reverse Scoring 36 months & older 80Does your child hop up and down on one foot?48 months & older 81 Does your child pedal a tricycle or other three-wheeled toy at least 6 feet? 48 months & older 82 Does your child walk down stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) S/he may hold onto the railing or wall. 48 months & older 83 Does your child wiggle their thumb, for example when using a tv-remote controller or video game controller? 48 months & older 84 Does your child unbutton one or more buttons, or unfasten one or more Velcro straps? Your child may use their own clothing or a dolls clothing. 48 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

24. THE PACIFIC HEALTH POLICY GROUP 24 #MilestoneApplies to: 85 Does your child use in, on or under in phrases or sentences? (For example, Ball go under chair; Put it on the table etc.) 48 months & older 86Does your child say their first and last name?48 months & older 87 Does your child follow instructions in if-then form? (For example, If you want to play outside, then put your things away etc.) 48 months & older 88Does your child share toys or possessions when asked?48 months & older 89 Does your child tell you the names of two or more playmates, including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.) 48 months & older 90Does your child brush their teeth?48 months & older 91Does your child urinate in a toilet or potty chair?48 months & older 92Does your child defecate in a toilet or potty chair?48 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

25. THE PACIFIC HEALTH POLICY GROUP 25 #MilestoneApplies to: 93 Does your child put on clothing that opens in the front (for example a coat or sweater)? (Does not have to button or zip the clothing.) 48 months & older 94 Does your child open doors by turning door knobs? (Includes doors that open/close with levers rather than traditional round knobs.) 60 months & older 95 Does your child identify and name most common colors (that is, red, blue, green, yellow)? 60 months & older 96 Does your child follow three-part instructions? (For example, Brush your teeth, get dressed and make your bed etc.) 60 months & older 97 Does your child take turns when asked while playing games or sports? 60 months & older 98 Does your child play informal group games? (For example, hide-and-seek, tag, jump rope, catch etc.) 60 months & older 99 Does your child put shoes on correct feet? (Does not need to tie laces.) 60 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

26. THE PACIFIC HEALTH POLICY GROUP 26 #MilestoneApplies to: 100 Does your child wash their hands using soap and water? (May be reminded.) 60 months & older 101 Does your child use the toilet by themselves? (S/he goes to the bathroom, sits on the toilet, wipes and flushes. May be reminded.) 60 months & older UPDATED PAS FOR CHILDREN UNDER 6 Developmental Milestones

27. THE PACIFIC HEALTH POLICY GROUP 1. Background and objectives 2. Updated PAS development steps 3. Whats changing and what isnt 4. Updated developmental milestones 5. Updated algorithm and weights 6. Maintenance of Effort 7. Questions 27 UPDATED PAS FOR CHILDREN UNDER 6 Topics

28. THE PACIFIC HEALTH POLICY GROUP UPDATED PAS FOR CHILDREN UNDER 6 Algorithm & Weights – Developmental Milestones 28 6 - 8 Mos 9 – 11 Mos 12 – 17 Mos 18 – 23 Mos 24 – 29 Mos 30 – 35 Mos 36 – 47 Mos 48 – 59 Mos 60+ Mos Age Cohort 9 milestones 19 milestones 28 milestones 44 milestones 56 milestones 65 milestones 79 milestones 93 milestones 101 milestones 6 - 8 Mos 5.000 9 – 11 Mos 4.100 12 – 17 Mos 2.900 18 – 23 Mos 2.125 24 – 29 Mos 1.750 30 – 35 Mos 1.550 36 – 47 Mos 1.340 48 – 59 Mos 1.140 60 Mos+ 1.030

29. THE PACIFIC HEALTH POLICY GROUP UPDATED PAS FOR CHILDREN UNDER 6 Algorithm & Weights – Medical 29 Medical Conditions / Medical + Developmental Combinations Age Cohort Cerebral Palsy Epilepsy Moderate/ Severe/ Profound MR Autism + MCHAT- Related* Autism + Behaviors* 6 – 8 Mos 5.0 9 – 11 Mos 5.0 12 – 17 Mos 5.0 18 – 23 Mos 5.0 7.0 24 – 29 Mos 5.0 7.0 30 – 35 Mos 5.0 7.05.0 36 – 47 Mos 5.0 15.07.010.0 48 – 59 Mos 5.0 15.07.010.0 60 Mos+ 5.0 15.07.010.0 *See next slides for definitions

30. THE PACIFIC HEALTH POLICY GROUP Autism + MCHAT-Related – 18 months & Older Diagnosis of Autism, PDD or Autism-like behaviors Fails at least six of the following MCHAT-related milestones: Does your child respond to their name when you call? If you point at a toy across the room, does your child look at it? Does your child ever use their index finger to point, to indicate interest in something? Does your child ever bring objects over to you? Does your child ever imitate you? For example, you make a face – will your child imitate it? Does your child take an interest in other children? Does your child like being hugged or cuddled? Does your child look at you when you talk to them? (Milestone introduced at 24 months) Note: Milestones also are scored individually and count toward 40-point threshold 30 UPDATED PAS FOR CHILDREN UNDER 6 Algorithm & Weights – Detailed Criteria

31. THE PACIFIC HEALTH POLICY GROUP Autism + Behaviors – 30 to 35 Months Diagnosis of Autism, PDD or Autism-like behaviors Exhibits at least three of the following behaviors: Does your child sleep at least 8 hours in a 24-hour period? (No response indicates presence of behavior) Does your child do things over and over and cant seem to stop? (Examples are rocking, hand flapping or spinning) Does your child destroy or damage things on purpose? Does your child hurt themselves on purpose? Note: Milestones also are scored individually and count toward 40-point threshold 31 UPDATED PAS FOR CHILDREN UNDER 6 Algorithm & Weights – Detailed Criteria

32. THE PACIFIC HEALTH POLICY GROUP Autism + Behaviors – 36 Months & Older Diagnosis of Autism, PDD or Autism-like behaviors Exhibits at least six of the following behaviors: Does your child sleep at least 8 hours in a 24-hour period? Does your child do things over and over and cant seem to stop? Does your child destroy or damage things on purpose? Does your child hurt themselves on purpose? Does your child cry, scream or have tantrums that last for 30 minutes or longer? Does your child act physically aggressive? (For example, hits, kicks, bites etc.) Does your child have eating difficulties? (For example, eats too fast or too slowly, hoards food, overeats, refuses to eat etc.) Does your child sometimes stare at nothing or wander with no purpose? Note: Milestones also are scored and count toward 40-point threshold 32 UPDATED PAS FOR CHILDREN UNDER 6 Algorithm & Weights – Detailed Criteria

33. THE PACIFIC HEALTH POLICY GROUP 33 Services and Treatments Age Cohort Drug Reg. and Admin. Non-B/B Ostomy Care Tube Feeding PT or OT* Acute Hospital Admits** Direct Care Staff Train Special Diet 6 – 8 Mos 1.07.0 1.01 x #0.52.0 9 – 11 Mos 1.07.0 1.01 x #0.52.0 12 – 17 Mos 1.07.0 1.01 x #1.02.0 18 – 23 Mos 1.07.0 1.01 x #1.02.0 24 – 29 Mos 1.07.0 1.01 x #1.02.0 30 – 35 Mos 1.07.0 1.01 x #1.02.0 36 – 47 Mos 1.55.0 1.51 x #1.02.0 48 – 59 Mos 1.55.0 1.51 x #1.02.0 60 Mos+ 1.55.0 1.51 x #1.02.0 * Capped at 1.0 or 1.5 points **Past year; capped at 2.0 points UPDATED PAS FOR CHILDREN UNDER 6 Algorithm & Weights – Services/Treatments

34. THE PACIFIC HEALTH POLICY GROUP UPDATED PAS FOR CHILDREN UNDER 6 Topics 1. Background and objectives 2. Updated PAS development steps 3. Whats changing and what isnt 4. Updated developmental milestones 5. Updated algorithm and weights 6. Maintenance of Effort 7. Questions 34

35. THE PACIFIC HEALTH POLICY GROUP 35 UPDATED PAS FOR CHILDREN UNDER 6 Maintenance of Effort AHCCCS intent is to maintain the existing eligibility standard, as defined in federal law Individual customer outcomes can vary between the current PAS and revised draft tool Pilot study results were analyzed to identify any program level impact. Findings for the updated PAS: Increase in eligibility by score for younger children, particularly under 12 months of age Decrease in eligibility by score for children 36 – 47 months Slight increase in eligibility by score for children 48 months and older The increase in eligibility for younger children will offset the effect to the 36-month old group over time

36. THE PACIFIC HEALTH POLICY GROUP 36 The impact at the program level on eligibility and financial impact should be neutral PHPG projected expenditures in year 1 would be 0.17 percent lower than would have occurred under the current PAS. Allowing for margin-of-error, this could mean a slight drop, increase or no change Note: There will not be any program-wide reassessment of currently-eligible customers using the revised tool Currently-eligible customers will not be reassessed using the revised tool unless they otherwise would have been reassessed using the current tool UPDATED PAS FOR CHILDREN UNDER 6 Maintenance of Effort