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Functional Assessments and Quality Improvement

Functional assessments are tools that states, providers, and managed care plans use to collect comprehensive information on persons applying for, and participants in, Medicaid home and community-based services (HCBS) and long-term services and supports (LTSS) programs.  Considerable variation exists among the specific functional assessments used across the country for Medicaid HCBS. However, they all have several purposes in common: supporting Medicaid level-of-care eligibility, person-centered service planning, and in some cases, development of individual service budgets.

Functional assessments most commonly include domains addressing activities of daily living, instrumental activities of daily living, memory and cognition, psychosocial and behavioral issues, functional health (e.g., vision, hearing, communication), and health status, as examples.

Functional Assessments and Data Standardization

Standardized items are a basic requirement for having electronically exchangeable information to allow the data to follow persons, regardless of where they receive services.

Ensuring data standardization within a functional assessment is necessary to:

  • Promote quality comparison across Medicaid and state HCBS programs,
  • Harmonize data elements with other Medicare and Medicaid sponsored post-acute care assessments,
  • Align person-centered data across all sources and requirements,
  • Allow data to follow Medicaid participants as they navigate different care providers (e.g., home health, skilled nursing facilities, hospitals, inpatient rehabilitation) to address health and physical challenges, and
  • Enable electronic exchange of HCBS data across continuums of care

Functional Assessment Standardized Items

Functional Assessment Standardized Items (FASI) is a set of reliable, valid person-centered standardized items that measure functional status and need for assistance with everyday activities among Medicaid HCBS participants. The FASI set may be downloaded here:

The Centers for Medicare & Medicaid Services (CMS), as part of the Testing Experience and Functional Tools (TEFT) Demonstration, tested the use of the FASI set and performance measures (PM) among HCBS participants to align with national efforts to create exchangeable data across Medicare and Medicaid programs.

Functional Assessment Standardized Items and Performance Measurement

CMS is the measure steward for two performance measures derived from FASI that assess and compare state performance related to person-centered planning.  These measures enable comparisons of the quality of care across settings and can help address the critical challenges states face in using meaningful HCBS quality measures to improve service delivery, to move toward person-centered planning, and to support core participant outcomes.  A Consensus-Based Entity endorsed FASI Performance Measure 1: Identifying Personal Priorities for FASI Needs in 2021 and FASI Performance Measure 2: Alignment of Person-Centered Service Plan with Functional Assessment Standardized Items Needs in 2023. Additional updates about the FASI measures will be published on the HCBS Quality Measures webpage

The FASI measures can be used by states to address, in part, the section 1915(c) waiver service plan assurance. The service plan assurance for HCBS waiver programs ensures that states design and implement an effective system for reviewing the adequacy of the service plans for waiver participants. The FASI measures can serve as performance measures for quality assurance related to service plan subassurance 1, which states: “Service plans address all members’ assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.”

The FASI measures also can be used to assess community integration and HCBS settings requirements for the Medicaid HCBS provided under sections 1915(c), 1915(i), and 1915(k), as defined in the HCBS Final Rule.

Functional Assessment Standardized Items and Interoperability

Building on more than a decade of work by CMS to develop standardized, interoperable assessment items, the FASI set has been added to the following standards and repository:

In 2020, CMS published the FASI set in the CMS Data Element Library, a repository for all standardized items used in CMS assessments and associated health information technology standards. The CMS Data Element Library promotes interoperable health information exchange and assists with standardization of assessment data elements to help facilitate care coordination.

In 2020, Logical Observation Identifiers Names and Codes, a common language for identifying health measures, observations, and documents, added Functional Assessment Standardized Items. LOINC Version 2.73 is available for public use.  This vocabulary set includes the FASI V1.1 (94848-9).

The Post-Acute Care Interoperability Project is a consensus-based, collaborative effort including policymakers, standards organizations, providers, and industry to advance interoperable health data exchange among healthcare settings, providers, patients, and HCBS participants.

In 2021, the Health Level 7 (HL7) Patient Care Work Group published the PACIO Functional Status Implementation Guide V1.0.0. The Functional Status Implementation Guide focuses on the exchange of healthcare information in three areas: mobility, self-care, and domestic life functioning. FASI facilitates the exchange of HCBS data elements across the LTSS health care continuum in support of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The work group intends to expand the Functional Status Implementation Guide in the future to include HCBS, caregivers, non-medical devices, assessment timeframes, and personal priorities.

Functional Assessments and Person-Centered Service Planning

Functional assessments support person-centered planning and support participants in articulating their goals and preferences related to their functional needs.

The FASI set includes documentation of personal priorities across multiple domains. The set supports Medicaid participants’ ability to identify personal goals related to their functioning; develop person-centered service plans; engage in decisions about the services and supports needed to address their functional needs; and execute their personal goals.

CMS will work with states to map their existing assessment instruments to the FASI. Additional FASI information can be found on the HCBS Quality Measures webpage