UAS and PRI/Screen for Transition Specialists Transition Center Nurses for MFP Christine Trimboli RN & Laura Bingell RN Open Doors is a Money Follows the Person program of New York Association on Independent Living under contract with New York State Department of Health. This document was developed under grant CFDA 93.971 from the U.S. Department of Health and Human Services, Center for Medicare &Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government.
Definitions PRI Patient Review Instrument A clinical tool used to assess a person s condition and the amount of care required for admission to an institutional setting and before discharge. Screen - A supplement done to better determine mental health, cognitive factors and resources available. UAS Uniform Assessment System A comprehensive assessment system designed to determine the amount of care required in home and community based settings. It includes supplements for Functional status and Mental Health status. (Adult, 4-17 years, 0-3 years)
Who Does It? PRI and Screen PRI - RN (Nurse Evaluator- NE) Screen RN or SW Qualified through NYSDOH contracted training program UAS RN SW (Assessor) Qualified by NYSDOH Health Commerce Web based training
Where Each is Conducted PRI- in the community, while hospitalized or on swing bed status, and prior to leaving NH UAS- in community, in facility prior to leaving, used by MLTCs and RRDCs for waivers to determine if minimum LOC is met https://www.health.ny.gov/health_care/medicaid/publications/gis/15ma011.htm
Nursing Home Resident SC will need a PRI and Screen less than 90 days old for submission to RRDC with waiver application Waiver participant UAS to be completed by NE (usually CHHA or LDSS) within 90 days of return to the community MLTC Contract with own NE/Agency
How Outcomes are Measured CAPs Clinical Assessment Protocols RUGs - Resource Utilization Groups Classification NFLOC Nursing Facility Level of Care What Do These Mean?
CAPS Clinical Assessment Protocol Key factors in an individual s life that indicate areas requiring additional needs and supports. 4 Areas of Focus Functional Performance Cognition and Mental Health Social Life Clinical Issues
Resource Utilization Groups Major classifications that people are assigned to based on clinical characteristics, functional status, complexity of care needed and cognitive status. The primary purpose of assigning a RUGs category is to calculate the relative cost for care in a facility.
NFLOC Nursing Facility Level of Care Based on scoring index that is uniform for all UAS assessments and programs now in NYS Uses information from the following portions of assessment-cognitive, Communication, Vision, Mood and Behavior, Functional Status, Continence and Nutritional Status Responses and observations in these areas are converted into points The higher the number the greater need for care 5 or greater qualifies for waiver services
Focus on UAS
Purpose of UAS Evaluates individual s health status/strengths and guides the development of a plan of care Assists with program eligibility determinations and identification of program options Improves care coordination and facilitates service delivery Improves communication about assessment information and reduces redundancy Ensures that individuals receive the right care, within the right setting, and at the right time
UAS Process Interview and observe the person, then consult with a family member(s), PCP and/or other caregiver(s). Focus on whether the person is actively managing tasks of daily living, not whether the caregiver(s) believe the person might be capable of doing so. THE FOCUS IS ON ACTUAL PERFORMANCE.
UAS - Areas Evaluated Cognition- Short Term and Procedural Communication and Vision Mood and Behavior Functional Status ADL, IADL, Mobility Continence Nutritional Status
UAS Components Bathing, personal hygiene, dressing of lower body, locomotion, and change in ADL status Functional Assessment Community Assessment Disease dx (schizophrenia), abnormal thought process, delusions, tobacco, alcohol, substance abuse, depression, cognitive performance Mental Health Assessment
CODING Choices Related to Function Independent Modified independence Minimally impaired Moderately impaired Severely impaired No discernable consciousness, coma
What person has actually done in the past 3 days What person is capable of doing in the professional opinion of evaluator
Areas Evaluated In Mental Health Supplement Mental Health Service History Mental State Indicators Self-deprecation, expressions of guilt/shame, irritability, hopelessness, inflated self-worth, pressured speech, racing thoughts, obsessive/compulsive behaviors, intrusive thoughts/flashbacks, substance use, unusual physical movements, hygiene, harm to self and/or others (attempts/ideations), suicide intent, expressions of concern by family, tendency toward violence, police intervention, stress/trauma, medications, family conflict
Mental Health Coding Choices Never More than 1 year ago 31 days to 1 year ago 8 to 30 days ago 4 to 7 days ago In last 3 days
6/12/14 Announcement from TBI Services Coordinating Council There is great concern many of New York s most vulnerable citizens, those with a documented traumatic brain injury (TBI) whom are currently being served by the New York State Department of Health TBI waiver, will be inaccurately assessed as not meeting level of care criterion, particularly if their primary disabilities are cognitive/behavioral and not physical.
The Alzheimer s Association The need for assistance with activities of daily living (ADLs) must be defined to include verbal assistance and the extent or severity of need must be determined by the duration of the assistance required, not the type of assistance. Level-of-care criteria must include measures of individuals need for supervision to protect them from the negative effects of impaired judgment and decision-making; impulsive inappropriate or disruptive behaviors; and other potentially harmful behavior such as wandering. These measures must be weighted appropriately so that people with severe impairments will be eligible.
Focus on H/C PRI and Screen
What is a PRI? HC-PRI = Hospital & Community Patient Review Instrument Assessment tool developed by NYSDOH Determines LOC and appropriateness of placement Assesses physical, medical, & cognitive characteristics Determines selected services
Sections of a PRI Administrative Data Medical Events Activities of Daily Living (ADLs) Behaviors Specialized Services Diagnosis Plan Of Care Summary
How a PRI Works Category Defines Medical conditions and treatments Need for rehabilitation Mental Health and behavior Scoring Reflects How much assistance or supervision is required with ADLs
Scoring -Eating How individual consumes food Level of independence with eating How maintains nutrition Need for verbal cuing Need for assist opening containers Need for assist cutting food
Scoring- Transfer Is physical assistance required Are transfers independent Intermittent supervision needed Assist for guidance, safety, steadiness Total dependence Equipment/Hoyer Lift/ Gait Belt
Scoring- Toileting Ability to get to toilet, bedpan, or commode Ability to maintain personal hygiene Ability to appropriately adjust clothing Assessing for continence/incontinence Incontinence briefs or pads Toileting/bowel regime
Categories - Special Needs Groups Heavy Rehabilitation Clinically Complex Severe Behavioral Reduced Physical Functioning
Requires restorative PT or OT 5 sessions/week Min. of 2.5 hrs/week Must be likely to improve Does not meet HR criteria ADL score of 5 or more 1 or more of following: stage 4 decubitus, suctioning, comatose, nasal gastric feeding, parenteral feeding, quadriplegia, or multiple sclerosis (MS)
Doesn t meet criteria for prior categories ADL score less than 5 One or more of following: dehydration wound care internal bleeding stasis ulcer daily oxygen chemotherapy dialysis urinary tract infection terminal illness blood transfusions 1 or more MD visits/week cerebral palsy
Exhibits behavior- infantile, disruptive, verbally/socially inappropriate or physical aggression Behaviors must be documented Behaviors 1/week for past 4 weeks Remaining individuals who did not meet prior criteria More custodial Can present challenge for appropriate placement
What is a Screen? Screen validates Level of care needed Qualification for NH placement Qualification for HCBS Need for supervision and oversight based on diagnoses of dementia/alzheimer s
Two Purposes of the Screen To determine potential for appropriate care in a setting other than a RHCF To assess those recommended for RHCF for possible mental illness, and developmental disabilities- requiring additional review instruments May trigger a Community Based Assessment
Community Based Assessment To determine resources available to an individual that would support living in the community. A person s environment Informal supports Economic resources Physical/Mental needs
Questions? https://www.health.ny.gov/forms/doh-694.pdf Web address to see PRI/Screen forms. Laura Bingell RN lbingell@ilny.org (607)962-8225 Christine Trimboli RN ctrimboli@ilny.org (518)538-6767