Pre-Admission Evaluation Tennessee — PAE Acuity Score for TennCare CHOICES

What the Pre-Admission Evaluation Is

The Pre-Admission Evaluation (PAE) is the clinical gate that determines whether a Tennessee resident qualifies for long-term care under TennCare CHOICES. It's not a financial assessment — that's a separate process. The PAE evaluates whether someone meets the medical standard for Nursing Facility Level of Care (NF LOC), which is the threshold for accessing both institutional care (Group 1) and home-and-community-based services (Group 2).

A physician, nurse practitioner, or physician assistant must complete the PAE and submit it to the TennCare LTSS Unit within 10 days of clinical certification. The evaluation scores the applicant on a weighted 26-point acuity scale measuring physical, cognitive, and medical deficits. The minimum qualifying score is 9 out of 26 points.

For families navigating a parent's dementia, the PAE is where everything either opens up or stalls. Score 9 or above and TennCare CHOICES becomes accessible. Score below 9 and you're left with private-pay options or the much more limited Group 3 at-risk services.

How the 26-Point Acuity Scale Works

The acuity scale is divided into domains that assess different functional areas. Each domain carries a maximum point value, and the points are weighted — some deficits count more heavily than others.

The domains cover:

• Mobility and transfer ability — Can the person move independently, or do they need physical assistance to get from bed to wheelchair, wheelchair to toilet?
• Continence — Bladder and bowel control, or the lack of it
• Eating — Can they feed themselves, or do they need prompting, hands-on help, or tube feeding?
• Orientation — Do they know who they are, where they are, and what day it is?
• Dementia behaviors — Wandering, combativeness, verbal aggression, resistance to care
• Medical treatments — Injections, wound care, oxygen therapy, and other clinical interventions

The scoring is cumulative. A person with moderate dementia who still walks independently, feeds themselves, and is continent might score only 4 to 6 points — well below the 9-point threshold — because the physical scoring categories carry heavy weight while the cognitive categories carry less. This creates a structural problem for dementia patients who are physically healthy but cognitively impaired.

The Safety Determination Pathway

Tennessee addressed this scoring imbalance with the Safety Determination pathway. If an applicant scores between 5 and 8 points on the acuity scale — close to the threshold but not quite there — a qualified assessor can submit additional medical documentation demonstrating that the person cannot be safely served in a lower-intensity care setting.

A Safety Determination may be approved when:

• The applicant has an orientation score of at least 3, and the lack of continuous supervision poses an imminent risk of harm to themselves or others
• A dementia behavior score of at least 2, with aggressive, wandering, or disruptive behaviors that create a severe and imminent risk of physical harm
• A history of severe, documented falls resulting in injury, combined with a mobility score of at least 3, where the absence of frequent physical assistance creates an imminent risk
• A sudden, significant decline in the physical or mental health of the primary family caregiver, leaving the applicant without necessary daily support

The Safety Determination isn't automatic. It requires supporting documentation — physician statements, incident reports, emergency room records, caregiver assessments. The assessor reviews this evidence and makes a judgment call about whether the applicant's safety needs justify NF LOC classification despite the lower acuity score.

Why Dementia Families Need to Understand This

The PAE scoring system wasn't designed with dementia as the primary diagnosis in mind. It was built to assess the full spectrum of conditions that lead to nursing facility placement — strokes, hip fractures, heart failure, advanced COPD. These conditions produce high physical deficit scores naturally.

Progressive dementia, especially in its middle stages, often presents the opposite profile: severe cognitive impairment with relatively preserved physical function. A parent who wanders out of the house at 2 AM, can't remember their children's names, and leaves the stove on — but who can still walk, eat, and use the bathroom independently — may score well below the 9-point threshold on physical assessments alone.

This is exactly the situation the Safety Determination was created to address. But many families don't know it exists. They receive a denial letter saying their parent doesn't meet NF LOC criteria, assume the decision is final, and either pay out of pocket for care or struggle to manage at home.

How to Prepare for the PAE

If your parent is approaching the point where long-term care is likely, preparation before the PAE is completed can significantly affect the outcome.

Document everything. Keep a written log of wandering incidents, falls, medication errors, unsafe behaviors, and emergency room visits. Date each entry. This log becomes critical evidence if the initial acuity score falls in the 5-to-8 range and you need to pursue a Safety Determination.

Talk to the evaluating physician. The PAE is completed by a medical professional, but the accuracy of the assessment depends on the information they have. Family caregivers spend far more time with the patient than any physician does. Make sure the evaluator knows about the 3 AM wandering, the time your parent tried to drive to a house they sold 15 years ago, the aggressive episodes during bathing.

Request the assessment in writing. Ask for a copy of the completed PAE form and the acuity score breakdown. If the score is between 5 and 8, you have grounds to request a Safety Determination — but you need to know the score to make that request.

Time the evaluation carefully. Cognitive function fluctuates throughout the day. Many dementia patients perform better in the morning and worse in the afternoon and evening (sundowning). If the PAE is conducted during the patient's best hours, the score may underrepresent their actual impairment. Discuss timing with the evaluator.

What Happens After the PAE

If the PAE confirms NF LOC (score of 9 or above, or an approved Safety Determination), the clinical eligibility gate is cleared. The applicant then moves to the financial eligibility assessment — income and asset limits, the Qualified Income Trust if needed, and the 60-month look-back review.

If the PAE does not confirm NF LOC, the applicant may still qualify for TennCare CHOICES Group 3 at-risk services, which carry a lower clinical threshold but also a lower benefit cap (approximately $18,000 per year). Group 3 is designed for people who don't yet meet nursing home criteria but are at risk of needing institutional care without intervention.

A denied PAE can be appealed. The family can request a formal review through TennCare's administrative hearing process, and the Safety Determination pathway can be pursued simultaneously. Having thorough documentation of the patient's behavioral and cognitive symptoms is what makes both the appeal and the Safety Determination viable.

For a complete walkthrough of the TennCare CHOICES application process — from the PAE through financial eligibility, the Qualified Income Trust, and enrollment — our Tennessee Dementia & Memory Care Guide covers every step with the specific forms, thresholds, and deadlines you'll encounter.

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