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Nebraska PASRR

PASRR 101Foundation and Process

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Andrea Womack, Director of Operations Brad Goodin, Program Manager

Introductions

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Agenda

• PASRR Overview

• PASRR Components

Level I

Level II

• New Online System

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PASRR Overview

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Risks associated with NF providers

• Historically medically focused (risks over-/under-treatment of behavioral health conditions)

• Limited professional training for disabilities (risks frustration, tolerance/intolerance)

• High turnover

Risks for people with disability in an institution

• Marginalization• Loss of skills• Extreme loneliness ( risk/death 14%1 ) • Early mortality (avg. 25–30 years with MI)2

• High rates of depression, suicide, “passive suicide”

• Shrinking world/loss/loss of control

PASRR mitigates those risk by:

Promoting transition and diversion; Naming community service and placement options

Promoting the individual’s right to choose

Educating providers about service/support needs

Demystifying the person’s disability

1University of Chicago, 20142Colton CW, Manderscheid RW. , 2006

Risks for People with Disabilities

Optimize an individual’s placement success, treatment success, and

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Structure & Purpose of PASRR

• Preadmission Screening & Resident Review

• Administered by Centers for Medicare and Medicaid Services (CMS) Created in 1987

• Anyone in Medicaid-funded NF screened for: Serious Mental Illness (SMI), Intellectual/Developmental Disability

(ID/DD), or Related Condition (RC)

• Known or suspected condition = evaluation To ensure NF is most appropriate placement To ensure receipt of needed services

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Legal Responsibilities for PASRR

Centers for Medicare and Medicaid Services (CMS): Federal Authority

• Publishes rules and guidance • Audits state compliance

State Medicaid Authority State MH Authority State IDD Authority

• Responsible for state PASRR compliance

• Sets & approves state PASRR policy not specifically given to another entity

• Level I by default

• Oversight of Level II PASRR activity

• Cannot do evaluations; can do the write up, etc.

• Oversight of Level II PASRR activity

• Can do the evaluation themselves

MAXIMUS: Delegated PASRR entity

• Often Level I • Often Level II evaluations • Often Level II write ups

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How do we reach that goal?

Provide Needed Services

Placement Meets Needs

Identify the Person

(Source: Dan Timmel, CMS, 8-13-2006, 2013)

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Required PASRR Components

• Level I (broad screening) Screening to determine presence of Mental Illness, Intellectual or

Developmental Disability or Related Condition (MI, IDD, or RC)

• Level II (PASRR individualized evaluation) Exemptions and categorical decisions

Onsite comprehensive evaluation

Offer level of care, placement, and treatment findings

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Required PASRR Components Cont.

• Level II Summary of Findings report and notification letters NF must:

• Keep copy in active chart

• Address all PASRR-identified services in plan of care

• Provide notification to individual and/ or representative

• Follow-up assessments Resident Reviews, Status Change, or Change in Condition evaluations

NF must report certain changes in conditions to the PASRR authority

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• Diagnosis (or suspicion of) a major mental illness• Dementia: If present, is it primary?• Duration• Disability

THE FOUR Ds OF PASRR—ID/RC THE FOUR Ds OF PASRR—MIintellectual disability/related condition

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Anoxia at birth

Arthrogryposis

Autism

Congenital Blindness

Cerebral Palsy

Congenital Deafness

Down Syndrome

Encephalitis

Fetal Alcohol Syndrome

Fredreich’s Ataxia

Hemiparesis

Hemiplegia

Hydrocephaly

Klippel-Feil Syndrome

Meningitis

Multiple Sclerosis

Muscular Dystrophy

Paraparesis

Paraplegia

Polio

PDD

Prader-Willi syndrome

Quadraplegia

Seizure Disorder

Spina Bifida

Spinal Cord Injury

Traumatic Brain Injury

XXY Syndrome

Possible PASRR Related

Conditions

Possible PASRR Related

Conditions13

• Least restrictive level of care– Too acute/not acute enough

• NF (meets LOC and this NF can meet needs)

– NF MUST incorporate ALL PASRR identified services into care plan

• Specialized Services

– Services specific to the person to meet required needs

• Alternative Placement or Community Services

#2: What is the most appropriate placement for this person?

#2: What is the most appropriate placement for this person?

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• Community placement– With or without supports

• Independent living

• Group home

• Assisted living

• Person-directed care

#3: Might this person be a candidate for transition to the community?

What supports or services would be necessary to return to the community?

#3: Might this person be a candidate for transition to the community?

What supports or services would be necessary to return to the community?

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• Specialized Services• Highest practicable physical, mental, and psychosocial well-being • Any needed service/support

– Not limited to facility’s existing resources

#4: What unique disability supports and services are needed while a resident of an

NF to ensure safety, health, and well-being?

#4: What unique disability supports and services are needed while a resident of an

NF to ensure safety, health, and well-being?

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PASRR Components

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Resident Review w/ Relevant Status Change

Level I Disability Screen

Level IIIn-Depth

Evaluation

Determination & Notification

Nursing Facility

Other Appropriate Placement

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Everyone receives a

Level I

Everyone receives a

Level I

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Level I Information

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Level I Determinations

• Negative screen = no PASRR condition• Can admit to NF • LI may include treatment recommendations

• Refer for Level II = has/suspected PASRR condition• Requires onsite Level II

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Categoricals and Exemptions

• Exempted Hospital Discharge—30 days• Respite—30 days

• Emergency 7 day

• Serious Medical Condition

• Primary Dementia / Secondary Mental Illness

• Progressed Dementia and IDD or Related Condition

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Exempted Hospital Discharge

30-day approval

Must be currently admitted to a medical hospital

Must be going to NF for treatment of the condition for which they were hospitalized

Expected to need NF for no longer than 30 days• If likelihood of over 30-day admission, not eligible for EHD

Must have a PASRR condition

Requires documentation:• Physician Attestation• Current H&P & other medical documentation to support exemption• Psych consultation, if completed

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Hospital Exemption Practice

1. Ms. Smith has bipolar disorder and was admitted to the hospital following a heart attack and bypass surgery. She developed an infection and needs 14 days of antibiotics. Her doctor certifies she will be ready for discharge within the first 30 days. Is Ms. Smith appropriate for the EHD?

― Yes: She had a hospital admission before NF admission and will need less than 30 days of NF

2. Mr. Jones has MDD. He had surgery after fracturing his hip in an accident. He will need 3 months of non-weight bearing status and needs NF placement to help with ADLs and PT. Is he appropriate for EHD?

― No. His anticipated NF care timeframe is more than 30 days

3. Ms. Johnson has Anxiety disorder and lives at home with her family. She has COPD and went to the Emergency room following a fall. She needs NF placement for treatment of her progressing COPD. Is she appropriate for EHD?

― No. She didn’t have a hospital admission, only an emergency department visit for her fall. She needs NF care for COPD, for which she is likely not to recover or discharge from the NF within 30 days.

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Respite 30 Days

The person’s care giver needs a respite

Must have a PASRR condition; psychiatrically/behaviorally stable

30-day approval or less

Expected to need NF for no longer than 30 days

• If likelihood of over 30 day admission, not eligible for Respite for 30 Days Categorical

Requires documentation:

• Physician Attestation• Current H&P & other medical documentation to support exemption• Psych consultation, if completed• Documentation supporting the need for respite

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Emergency 7 Day Categorical Must have a PASRR condition

This categorical is applied when a person has experienced a crisis such as loss of a care giver or loss of a residence, etc.

Submit a Level I PASRR

Requires documentation:

• Physician Attestation

• Current H&P & other medical documentation to support exemption

• Psych consultation, if completed

• If a longer stay is required after admission, the Nursing Facility will need to submit a new Level I PASRR as soon as possible to allow for a Level II PASRR to be completed prior to the expiration of this Categorical.

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Serious Medical Categorical Decision

Must have a PASRR condition

The condition renders him/her unable to benefit from PASRR-identified services

Applicable conditions include coma, ventilator dependence, brain stem injury, and an end-stage medical condition

Requires nursing care or supervision due to his/her physical condition

Requires documentation

• Physician Attestation• Current H&P & other medical documentation to support exemption

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Primary Dementia/Secondary Mental Illness

• Progressed dementia Advanced and unable to participate in specialized services

• Report method of diagnosis

• Must include documentation supporting diagnosis and stage of disease. Some examples are: Neurocognitive assessments reporting diagnosis and progression/severity of

condition

Other medical documentation supporting diagnosis and progression/severity of condition

If it is unclear if the dementia is progressed and primary, a full Level II will be conducted to further assess

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Progressed Dementia/ID/RC

• The individual must have a confirmed diagnosis of an Intellectual Disability prior to age 18 or a Related Condition prior to age 22

• The individual must have a diagnosis of Dementia

• The Dementia diagnosis must be classified as primary

• The individual must be considered to be in the advanced stages and unable to participate in or benefit from PASRR-identified services

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Submit Level Is:

For everyone admitting to a Medicaid-certified NF, regardless of pay source

• Before NF admission Pre-Admission

• Expiration of a time-limited stay Resident Review is required before expiration

• Submit a new Level I to initiate the process Submit at least 7 days before expiration date

The Start Date of the Approved Level I is the date of the PASRR and not the date of the Admission to the Nursing Facility

• Significant change in status Resident Review

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Level I Best Practice

• Federally compliant 100% PASRR Technical Assistance Center, PTAC/CMS score Pre-admission

Sensitive, yet specific (some false positives, but not too many)

Quality Review

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“Go Fast” Checklist for PASRR Level I Process

Fill out submission correctlyo Most common issues are:

o Incorrect medication dosage/medication not listedo Incorrect diagnoses—don’t guess based on prescribed medicationso Incorrectly filling out the ID/RC portion

When to mark functional limitationso Submitting incorrect SSNs and DOBs

Submit supporting documents o H&P, OBRA 8, Guardianshipo Submit psychiatric evaluation if conducted during hospital stay

Be patient with the processo Clinicians will work the screens in the order received. They cannot re-prioritize from

a call

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Best Practices with Regard to Submitting a PASRR

• Be mindful of when to submit a Level I PASRR – Typically the earlier the better

• Don’t wait until an hour before discharge from a hospital to complete the PASRR

• Alert Ascend if the person has discharged to a location other a Nursing Facility and the Level I is pending

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Common Problems for Level I

Knowing when to submit a new Level I

• Resident Review/Status Change

• Expiration of a time-limited stay

• Preadmission

Incorrect information on the Level I

• Missing/Incorrect demographics

• PASRR Conditions

• Medications and reason for prescription

• Attestation of accuracy

Understanding the outcomes

• Exemption & Categoricals—begins at the completion of the PASRR, not at the time of admission to the NF

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PASRR Level II

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Importance of the Level II

• In-depth assessment Meet the person for bio/psycho/social interview Interview support/care providers Review medical records

• Describes the person’s: Likes/dislikes History Needs/Diagnoses

• State and Federally required

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After the Assessment

• Determination

• Summary of Findings report

• Consideration of placement options

• Level of Care

• PASRR-identified services

NF must know it is able to deliver allof these

The Level II Summary of Findings Report has critical information NF providers must review

to determine if they can deliver the identified

services to the person

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Level II Outcomes

• Short-term approval

• Long-term approval

• Denial, requires Specialized Services = psych stabilization

• Denial, does not meet LOC

• Halted (Ruled Out of PASRR) NOTE! LOC/placement decision is not made by Ascend when when a LII is

Halted

Start dates of Level II approvals are at the time of the PASRR completion and not the date at which the individual admits to the Nursing Facility.

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Common Problems for Level II

Understanding the outcomes

• Long-term vs. Short-term determinations

• Understanding meaning of a Halted Review

Incorporation of identified services into the care plan

• Reviewing & understanding the needed PASRR services

Knowing when to submit a new Level I

• Resident Review/Status Change

• Expiration of a time-limited stay

• Preadmission

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Discharge Planning—Hospitals

• Begins at admission

• Avoids discharge delays

• Ensures timely completion of Level II when needed

• Provides opportunity for NF to ensure they can meet person’s needs

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Discharge Planning—NF

• After Admission

• NF must incorporate ALL PASRR-identified services

• Care Plan must include (within 21 days):• Start date of each service

• Name and credentials of provider

• Expected frequency

• Anticipated duration

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What is PASRR Compliance?

•Preadmission

Occurs before admission to NF

Level I submission is responsibility of the Hospital, AAAD, and MCO

NF must ensure individual is not admitted without having a completed PASRR

• NF must review the PASRR outcome prior to admission

Includes Level II process

•Resident Review

Occurs after admission to NF

Change in status

NF’s responsibility

Includes Level II process

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Short Term Approval and Discharge Planning

• Time is of the essence

• Don’t expect that another short term PASRR will definitely be approved• This could be the last approved PASRR

• Be creative in where you might locate a service identified as Community Placement Support• Volunteers

• Paid supports

• Community groups

• Family/friends

• Religious organizations

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4/1/2017 to 4‐30‐18 4/1/2017 to 4‐30‐18

All Clinically Reviewed Level I ‐ Business Hours All Level II ‐  Calendar Days

Federal Timeframe 7‐9 Business Days

Turnaround Times

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AssessmentPro

System Improvements

Coming Soon

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AssessmentPro

• New system

• New access link

• More access to records from your facility/agency

• Similar Level I screen

• Level I and Level II outcomes

• Communicate with Ascend/MAXIMUS in the system

• Upload documentation

• Same quick turnaround time

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AssessmentPro Training Dates

Tuesday, June 26, 2018 11:30 a.m. - 12:30 p.m. CST

Wednesday, June 27, 2018 4:00 p.m. - 5:00 p.m. CST

Thursday, June 28, 2018 9:00 a.m. - 10:00 a.m. CST

Monday, July 9, 2018 10:00 a.m. - 11:00 a.m. CST

Training coming soon!

System use starts on July 9, 2018

Questions?