Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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8/16/23  3:41 pm
Commenter: Rachel Evans, No Limits Eastern Shore


The manual uses the validated Mayo-Portland Adaptability Index (MPAI-4) as the tool to determine that the Traumatic Brain Injury (TBI) is severe enough for TCM eligibility. DMAS provided a training this spring for potential TCM providers that was given by the MPAI-4 developers.

In that training, we were told that to correctly administer an MPAI-4 assessment we need to be familiar with the individual, have access to past records, and be experienced with the tool itself. This is supported by language in the Manual for the MPAI-4, which states on page 3, under Test Materials and Use: User Qualifications:

"User Qualifications - The MPAI-4 may be completed by people with ABI, their SO, medical or rehabilitation professionals, and other designated observers who know the individual well. People with very severe cognitive impairment should not be given the MPAI. Professional staff should review the rating guidelines provided in this manual prior to making ratings. People with ABI or their SO should have a professional who is experienced with the MPAI-4 review the rating guidelines with them prior to making ratings and be available to them to answer any questions that may arise during their completion of the inventory.

Currently we recommend that people with ABI and their SO complete the same version of the MPAI as staff. In clinical practice, comparisons among independent ratings by staff, people with ABI, and their SO can offer information about the varying perspectives of each of these rater groups. Examination and discussion of these varying perspectives are often critical for effective rehabilitation planning, as well as for revealing more subtle problem areas.

Scoring and interpretation of the MPAI-4 require professional training and experience. Ideally professionals with advanced training in tests and measurements will be available to clinical teams that use the MPAI-4 for clinical evaluations. Such a skilled psychometrician should also be involved when the MPAI-4 is used for program evaluation or research. Interpretation of the MPAI-4 by professionals in the clinical setting requires specific experience with the instrument and with ABI in addition to basic knowledge of tests and measurements."

Please note that it references that scoring & interpretation require professional training and experience & that ideally professionals with advanced training in tests & measurements will be available to clinical teams that use it for clinical evaluations. A professional with MPAI-4 experience is supposed to review the ratings with survivors & their support circle.

This dovetails with DMAS' own words, on page 11 of this manual revision, where they specifically state, "Scoring & interpretation of the MPAI-4 require professional training and experience."

Despite the words of the MPAI-4 creators and DMAS, this manual expects the TCM case manager (who, if we cross-reference the CM requirements, could be a person with zero ABI experience & a bachelor's degree in Aeronautical Engineering who took a 2 day direct care level QBISP training that expects them to operate under daily supervision) to administer the MPAI-4 as an entry point eligibility screening tool. 

It was not designed to be used as a screening tool to determine service eligibility, or to be administered by someone unfamiliar with it, or to be administered by someone who has no familiarity with the individual &/or access to their history. The MPAI-4 Manual states, "The Mayo-Portland Adaptability Inventory (MPAI) was designed:

? to assist in the clinical evaluation of people during the postacute (posthospital) period following acquired brain injury (ABI),

? to assist in the evaluation of rehabilitation programs designed to serve these people, and

? to better understand the long-term outcomes of acquired brain injury (ABI). ".

If DMAS wants it to be used as the gateway to service entry, there needs to be clearer guidance and standards regarding who is qualified to administer it. Remember, a survivor of TBI could be denied supports based on the scoring & rating ability of the person administering the MPAI-4. Even more chillingly, per DMAS staff, the MPAI-4 will be required to be administered annually and if supports are effective & the individual's score increases they will be deemed ineligible for the service (I guess the plan is we wait for them to decompensate, test them again, & get them back into services?).

Perhaps the MCOs should be determining eligibility. It seems like there is a potential conflict of interest in allowing providers to rate individuals themselves, given that a less ethical or less trained provider could theoretically place their thumb on the scales by adjusting their scoring to ensure that an individual qualifies or doesn't qualify. At our agency, 2 qualified staff can come up with 2 different ratings scores for the same individual. The ratings can be subjective & rely on having good knowledge of the person & their history. Considering that, it seems like at a minimum this is an area where an individual should be allowed to appeal a rating or request a 'second opinion' screening by a different rater. What about when Mom's ratings conflict with the individual's ratings &/or the professional's ratings? How is that resolved in this system?

This is a sophisticated, validated, nuanced tool that by all accounts requires trained & experienced administrators. It might make more sense to allow preliminary entry into services based on medical records and a comprehensive functional assessment, especially considering the vast fluctuations that ABI survivors can have between 'good days' & 'bad days', with an MPAI-4 administered perhaps around the 90 day or 6 month mark to verify continued eligibility.



CommentID: 218775