Preadmission Screening for Medicaid Certified Nursing Facilities. Department of Human Services Med-QUEST Division 2016

Transcription

1 Preadmission Screening for Medicaid Certified Nursing Facilities Department of Human Services Med-QUEST Division

2 Agenda History Specialized Services Hawaii s Revised Level I Screening Tool Level II (Evaluation and Determination) Resident Reviews Questions 2

3 The Omnibus Budget Reconciliation Act (OBRA) 1987 Institutional Care Settings in the 80s Closures or Downsizing Individuals with a Serious Mental Illness (SMI) or/and Intellectual Disabilities or Developmental Disabilities or Related Condition were being institutionalized without adequate mental health services, therefore: ALL APPLICANTS TO A MEDICAID CERTIFIED NURSING FACILITY REGARDLESS OF PAYOR SOURCE ARE REQUIRED TO, PRIOR TO ADMISSION: Determine if applicant is SMI, ID, DD Determine if applicant meets Nursing Facility Institutional Level of Care Determine if applicant s needs could be met in a Nursing Facility, and Determine if applicant requires Specialized Services Current Specialized Services for SMI Requires 24 /7 Behavioral Health Active Treatment Plan Current Specialized Services for ID, DD Requires 24/7 Active Treatment Plan 3

4 CMS Review of Hawaii s Screening Tool Recommendations: Needing more definitions to Broadly Screen applicants Hawaii added additional screeners Hospital RN Discharge Planners and APRNs 4

5 Revised Level I Screening Tool DHS 1178 Form Demographic Information Part A Serious Mental Illness (SMI) Part B Intellectual Disabilities, Developmental Disabilities/related condition (ID,DD) Part C Categorical Determinations 5

6 Part A Serious Mental Illness (SMI) Answer: Yes or No Definition - #1, a, b Listed affected function, added substance related disorder SMI may lead to a chronic disability SMI is current SMI is NOT primary or secondary of Dementia / Alzheimer s SMI is NOT under the Dementia Umbrella as a listed diagnosis SMI is a stand alone diagnosis, behavior is not coming from the Dementia If SMI stand alone and has Dementia, show evidence (not new) In the last two years have psychoactive medications been prescribed on a regular basis with or without current diagnosis of SMI 6

7 Part B Intellectual Disability (ID) Developmental Disabilities (DD)/Related Condition Has ID or history of indicating the presence of ID prior to age 18 Has DD/related condition indicating presence prior to age 22 (indicate age of presence) closely related to Intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of intellectually disabled persons and required treatment or similar services Autism, epilepsy, blindness, cerebral palsy, closed head injury, deaf Must have substantial functional limitations in three or more of the following areas of major life activity Self care, understanding the use of language, learning, mobility, self direction, capacity of independent living Has ID, DD and Dementia show evidence (not new) Has functional limitations relating to ID, DD Received or receiving ID, DD services Indicate service agency 7

8 Negative vs. Positive Screen All NOs in part A and B = a NEGATIVE screen Sign, print name, and date Ok to admit applicant if applicant meets nursing facility institutional level of care If YES in part A or B = a POSITIVE screen If applicant is POSITIVE, then go to Part C (Categorical Determinations) 8

9 Positive Screens Part C Categorical Determinations Categorical Determinations are pre determinations that the applicant at the time of screening, does not benefit from specialized services 1 Discharged from Acute Care, needs rehabilitative therapy 2 Terminal Illness 3 Comatose, Ventilator Dependent, Functioning at Brain Stem Level 4 Delirium 5 Protective Services 6 Respite Care (short term, to return to same caregivers) 9

10 Part C Categorical Determinations If yes on one categorical determination (only one can be checked), a Level II evaluation and/or determination may not be needed preadmission Ensure that the definition meets the applicant s current status Watch timelines since categorical determinations may have grace days Level II is required at the end of the grace days or after rehabilitation (on #1) if applicant continues institutional nursing facility stay If ALL NOs on Part C a Level II Evaluation and/or Determination is REQUIRED before admission into the nursing facility Sign, print name, and date 10

11 Level II Evaluation Adult Mental Health Forms Attending Physician and a Psychologist or Psychiatrist No affiliation with AMHD Form 2 Medical Evaluation Form 3 Psychiatric Evaluation, part I Form 4 Psychiatric Evaluation, part II If found not meeting SMI PASRR on form 4, ok to end evaluation 1147 if applicable Developmental Disabilities Division Form Attending Physician and a Psychologist or Psychiatrist Long Blue Form Add a Social Summary 1147 if applicable 11

12 Level II Evaluation Complete forms Other reports can be utilized in place of forms, i.e. history and physical done that reflects applicant s current condition can be used in place of the Medical Evaluation Fax, mail forms to: AMHD DDD Or both for Duals Determination letter will be sent to the sender, MD, and applicant 12

13 Level II Determination Letter Letter will be sent to sender, MD, applicant and will state: whether applicant meets SMI, ID, DD whether applicant meets Institutional Level of Care whether applicant needs Specialized Services Appeal Rights If SMI, ID/DD applicant does not meet Institutional Level of Care No admittance to Institutional care facility If applicant requires specialized services Do not admit State must divert applicant who needs specialized services SMI Acute Behavioral Health Unit ID/DD Home and Community Based Waiver or Intermediate Care Facility 13

14 Resident Review Continuing Residents in a Nursing Facility Significant Change in Status / Minimum Data Set (MDS) After a change in physical or mental condition Care Plan reassessment by seventh day Comprehensive Assessment by 14 th day Complete a Level II by 21 st day if resident s condition warrants review for specialized services 14

15 Questions Is this preadmission screening requirement only for applicants wanting to reside in a Medicaid certified nursing facility? YES Is preadmission screening required for all payor sources? YES Do we need to do PASRR for any community settings? NO 15

16 Contacts Med-QUEST Kathleen Ishihara, RN, Nurse Consultant, or Health Services Advisory Group (HSAG) Elizabeth Marsh, RN, PRO Project Manager, , or Adult Mental Health Division Dr. James Westphal, , or Fax Developmental Disabilities Division Stephanie Guieb, RN, , or Fax