Welcome to Ascend s PASRR training for Iowa PASRR Providers. Thank you for attending Appreciate our relationship, look forward to developing new ways to work with providers and services to help the people of IA. In October, we were Looking to the Future by Strengthening our Foundation. We couldn t move forward until we are all on the same page and have a consistent focus on the Iowans in PASRR. So now, we are going to build on that stronger foundation. We are going to build our knowledge together to continue to improve the lives of Iowans. 1
Before we begin the PASRR review, we want to celebrate you. Since 2011, we have revamped the PASRR program in IA and, although it hasn t been easy, you have hung in there with us through the growing pains. The changes have made the lives of Iowans better and made IA compliant with both state and federal regulations. But we aren t done yet. We can explore new processes, make more improvements, and continue to grow and adapt to lead the way in PASRR. 2
As you can see, you have done a lot since Ascend began working with IA. We know there have been some challenges and we want to assure you that you have done a GREAT job! 3
An increase in status changes reflects improved knowledge of PASRR. Stable volume of status changes, probably good. Decrease in status changes, probably means we are missing people. You guys are doing a good job. Status change volumes have definitely increased since 2012 and have remained stable over the past two years. You see in the 1 st quarter of 2016, there was a huge increase in status changes, this is most likely explained because PathTracker Plus became mandatory on February 1, 2016 and nursing facilities were entering all there residents into PathTracker. 4
Document percentage: compliance issues over total Level I referrals. 5
Blue represents facilities that have accepted residents with Level II conditions, who did not require specialized services. 6
Green represents facilities that have accepted residents with Level II conditions, who did require specialized services, you can see that many facilities are accepting residents with LII conditions, and many of the same facilities are also accepting individuals who require specialized services. This information is based on Pathtracker facilities from the query starting in January 2016 up until February 2017. Total SNFs, NFs and NFMIs in Iowa: 458 Total Admitting facilities in Pathtracker: 449 Within these PathTracker facilities, 287 accepted individuals with LII conditions, 207 of these have approved an SS outcome at least once since Jan 2016. 7
So we just spent some time celebrating Iowa, I m going to take a few minutes to discuss Ascend now. Ascend, A MAXIMUS Company is an internationally recognized leader in healthcare management services. Our corporate headquarters is located in Reston, Virginia, and Ascend s offices are located in Franklin, TN, just south of Nashville. We strives to promote excellence, innovation, integration, and integrity through a broad continuum of management and consulting solutions which maximize quality of services. And we believe that we have a responsibility to serve all stakeholders affected by the projects with which we work. This includes individuals and families, providers, caregivers, and state agencies. It also includes the Center for Medicare and Medicaid Services and the taxpayers. Ascend s mission is helping government serve the people. 8
We have talked extensively about the fundamentals of PASRR in the past several onsite meetings we have had, so this time we are only going to do a quick refresher to get everyone on the same page and then we are going to talk about some advancements and dig a little deeper into the wonderful world of PASRR, what some might call PASRR 201. Lots of info available on PASRR.com and Ascendami.com if you need more explanation/depth 9
The big picture is that PASRR is important because it ensures that people with disabilities receive the services they need while in a nursing facility, and because it identifies and reports about the services and supports people will need to make the transition back into their communities. PASRR mitigates risk by minimizing vulnerabilities. People with disabilities have many more risks than people without them. In facilities, we see greater loss of skills, and higher risk for marginalization, because providers don t always understand the person s symptoms or communication from the individual. This increases the person s sense of loss, loss of control, and the idea that their world is shrinking. All of this can lead to increased loneliness and earlier mortality. From the beginning, PASRR requirements help minimize any potential vulnerability by educating providers about the person s service/support needs letting you know what is important to and for the person. Divert/transition ensuring the person receives the best care at the least restrictive level of care to have the highest practicable quality of life. Ensure admitting facility can meet the individual s needs if you can t meet the person s needs, neither the NF or the individual will be successful in the delivering or receiving care 10
Demystify the disability clarify how the individual can best be supported we help you know the person and give you any insights about what might help them be successful Build relationships talk to the people, they are the experts on their lives. 10
PASRR stands for Preadmission screening and resident review. This federally mandated screening process dates back to 1987 through language in the Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act. The process is Administered by the Centers for Medicare and Medicaid Services (CMS), and allows considerable discretion for states, and differs widely from one state to another. In Iowa, the Department of Human Services has contracted with Ascend to facilitate the PASRR Level I screening and Level II evaluation processes. PASRR requires that anyone seeking admission to a Medicaid certified NF be screened to identify the presence of serious mental illness, intellectual disability, or developmental disability or related condition. If a qualifying condition is known or suspected, regardless of service receipt, an individualized evaluation must be conducted to ensure that the nursing facility is the most appropriate place for the person to live and receive needed services. 11
The central intent of PASRR is that NF applicants and residents with MI/IDD/RC conditions are: 1. Identified. This happens with the Level I 2. Given an in depth evaluation to determine their needs and appropriate placement. This occurs with the Level II and LOC 3. Provided Specialized Services determined with the Level II. Specialized services are those services that are unique to the person for treatment/support of their PASRR condition. 4. Allowed to admit or remain in a NF only if they will receive the services/supports they require. If the NF cannot meet the person s unique needs, neither the NF or the individual will be successful there. 12
If you look under the hood of all the regulations and rules, what you ll find is that the ultimate goal of PASRR is to optimize an individual s placement success, treatment success, and ultimately, an individual s quality of life. Established as part of the deinstitutionalization process, PASRR works to ensure people with disabilities are not inappropriately institutionalized or marginalized; that every individual receives the needed services and supports in the least restrictive setting possible. This means that we must also focus on what supports and services they may need to remain in or return to the least restrictive and most integrated setting (LOC) that is consistent with their needs and wishes. 13
For a PASRR to be effective and meaningful to and for the individual, in addition to being federally compliant, it must answer four questions. 1. Does the individual have a PASRR (LII) condition? 2. What is the most appropriate placement for this individual? 3. Might this individual be a candidate for transition to the community? What supports or services would be necessary to remain in or return to a lower level of care in his/her community? 4. What unique disability supports and services does the individual need while a resident of an NF to ensure safety, health, and well being as well as any that might help the person return to a lower level of care? We will explore the meaning of these 4 questions on the following slides. 14
The first of our four questions asks: Does the individual have a PASRR condition? This means, does the person have a known or suspected diagnosis of a serious mental illness or intellectual/developmental disability. In PASRR, a developmental disability is also known as a related condition that is a condition related to an intellectual disability. To answer this question, lets examine the 4 Ds of PASRR: Diagnosis, Dementia, Duration, and Disability. Diagnosis examines the presence or suspicion of a serious/significant mental illness or IDD. Serious mental illnesses can include Schizophrenia, Bipolar Disorder, Depression, and others. Just because a person doesn t yet have a formal diagnosis doesn t mean they don t have a condition; sometimes the first episode of depression can have a major effect on the individual, for which they need services and supports. Sometimes a person goes their entire lives not receiving IQ testing or services because the family provided all of the support needed this is the heart of PASRR: identifying people with PASRR conditions who need services and supports and ensuring they receive them in a meaningful way in the least restrictive appropriate environment. The second D is for dementia; we must confirm the person does not have primary dementia. This means people whose dementia is advanced to the point that active treatment or intervention for their mental illness may no longer provide significant benefit; that their dementia is their primary condition. You will notice that our second D, dementia, is not included when evaluating the Ds for intellectual disabilities. This is because people with ID/RC often continue to receive similar services, regardless of a dementia diagnosis and people with both ID/RC and dementia can continue to benefit from PASRR oversight. The third D is duration. We look to see if the person has had any significant life disruptions because of the disorder. These disruptions can include hospitalization, loss of housing, jobs, or legal issues. The final D is Disability. For this, we examine the individual s symptoms specifically related to interpersonal functioning, concentration/pace/persistence, or adaptation to change. Because PASRR is designed for people who meet the specific criteria of a known or suspected diagnosis of a serious mental illness, it is important that we do not include people who do not meet the program parameters. This permits us to exclude from LII, certain people who are experiencing situational emotional reactions, people prescribed psychoactive medications for non psychiatric conditions, or people with advanced dementia that may no longer benefit from services or supports for treatment for their mental illness. Although a person doesn t have to meet all four of the Ds, these categories help us understand if a person belongs in PASRR population. Because PASRR is not including these people in PASRR population, the nursing facility is responsible for determining the individual s plan of care, without input/oversight or regulation by PASRR. 15
Related conditions is a term that PASRR uses to describe developmental disabilities because it results in similar impairment of general intellectual functioning and/or adaptive behavior & requires similar treatment or services. Some examples of related conditions are available on this screen. This is not an exhaustive list, although it represents examples of what could be considered a related condition. However, the existence of a diagnosis/condition alone does not automatically mean a person meets PASRR criteria. We examine how the condition affects the person s functioning and at what age the person needed support related to the condition. PASRR indicates the person must have 3 or more functional limitations from a condition diagnosed before the age of 22 that will last indefinitely. The areas of functional limitation in major life activities are: self care, understanding and use of language, learning, mobility, self direction, capacity for independent living. 16
The second of the four questions is: What is the most appropriate placement for this individual? (Is the placement acute enough or too acute). To answer this question, we must determine what the least restrictive level of care is for the individual and determine if the person has needs that require additional services because of mental illness, intellectual disability, or a related condition. This could mean additional NF services, like psychiatric medication monitoring, individual therapy, inpatient psychiatric hospitalization, ICF/ID placement, or some version of a community placement with services, like home health or case management. We need to know what the person needs and what the best environment is to meet those needs in a way that does not marginalize or institutionalize the individual. 17
Question 3 asks Might this individual be a candidate for transition to the community? What supports or services would be necessary to return to his/her community? By this, we must determine if the person s needs can be met in a community or otherwise less restrictive setting. This can include independent living with or without services like home health, meals on wheels, or environmental adaptations; or living with structured supports, as in a group home or shared environment. It is necessary to understand not only what the person needs, but also what the person wants. Every person has the right to direct their care and to an optimal (least restrictive, most integrated) living environment. 18
Question 4 asks what unique disability supports and services does the individual need while a resident of an NF to ensure safety, health, and well being? CMS charges nursing facilities to provide services and supports so the person can attain the highest practicable physical, mental, and psychosocial well being. These Specialized Services are any service or support identified through an individualized Level II determination that a particular nursing facility resident requires due to mental illness, intellectual disability, or related condition, that supplements the scope of services that the facility must provide under reimbursement as nursing facility services. These can include anything the person needs and we should not limit our findings based on what a facility or community can provide or currently provides. It is possible that an alternate facility can provide the needed services or secondary community resources can be used. We can also examine comparable or similar services in lieu of any findings given. For example, if a PASRR identified service is for a psychiatrist to provide ongoing medication management and the facility does not have a psychiatrist on staff, the NF can work with community providers to arrange, schedule with a psychiatric ARNP, or possibly use Telepsychiatry. 19
Next, let s talk about the components of PASRR and how we use them to answer the 4 questions. 20
Here is how we answer those 4 questions. The first step is the Level I screening. This screen identifies if the person could potentially meet PASRR criteria. This is a broad screening to identify the presence or suspicion of a disability condition. Every person admitting to a Medicaid certified nursing facility, regardless of the individual s pay source, must have a Level I screen conducted. If a disability is present or suspected, regardless of service receipt, the individual is referred for a Level II evaluation. If the Level I screen indicates no disability is present or suspected, then no further PASRR activity is required prior to admission to a nursing facility. The second phase, the Level II, is the information gathering portion of PASRR. This is where we learn about the individual and his/her diagnoses, history, medical presentation, and needed services and supports. Level II evaluations are individualized. They evaluate the suspected PASRR condition and make level of care, placement, and treatment findings. Some Level II decisions are abbreviated, and can be completed using information submitted as part of the online Level I process. Some Level II evaluations require a comprehensive onsite evaluation by an Ascend clinical professional. The third phase is the determination. Ascend s clinicians provide Level II decisions in Iowa regarding the individual s Level of Care (placement) and service needs. They include PASRR
identified services to ensure the person receives the necessary care and supports. As we discussed earlier, the facility is responsible for arranging any PASRR identified services to ensure the individual can attain the highest practicable physical, mental, and psychosocial well being. This summary is a legal document with PASRR identified service needs regarding placement and treatment. Nursing facilities must keep a copy of this summary in an individual s clinical chart at all times. PASRR identified services must be addressed in the nursing facility s plan of care. PASRR identified services must be delivered. Finally, PASRR laws also mandate that nursing facilities notify the PASRR authority when an individual experiences certain changes in status. These follow up PASRR evaluations may be called resident reviews or change in status evaluations. Sometimes these are conducted as paper based reviews, and sometimes they lead to in person on site LII evaluations. In Iowa, all resident reviews or status change PASRRs begin by submission of a LI screen, in exactly the same manner that all preadmission PASRRs are conducted. PASRR law ensures that nursing facilities continue to monitor individuals with disabilities for placement and treatment appropriateness. 21
Let s talk more about the determination options: Negative screen this means the person does not have a PASRR condition and can enter a NF as needed. Remember, a PASRR condition is a Major mental illness, intellectual disability, or related condition. Some LI reports include PASRR identified services. These are not binding on the NF, because the person has not been determined to be in the PASRR population, but may provide useful ideas to help improve quality of life and addressing various health conditions for individuals. Refer for Level II this means the person does have a PASRR condition and will need to have a Level II evaluation and summary before he/she can be admitted to a NF. 22
Iowa also has categoricals and exemptions. These are special circumstances for a person to go to a NF without having a full level II evaluation. They all have time limited stays, meaning if the person will be in the NF longer than the approval period, the NF will have to submit a new Level I and the person will likely require a full level II. One comment about categoricals and exemptions. These are designed for people who will either likely not benefit from PASRR identified services or will not be in the NF long enough to receive benefit from them. If a person will likely be in the NF longer than the identified approval period, such as more than 30 days for an exempted hospital discharge, they will not be eligible for the exemption. These are not designed to be a short cut around the Level II and Ascend will look closely at misidentified application of criteria. Failure to report accurate information on the person is fraud and can cost the state and taxpayers money unnecessarily. Also, even if the criteria applies, it is possible the individual will not receive an exemption or categorical outcome. The person s stability and determination of medical necessity are paramount when making an outcome determination. Ascend will require specific documentation for each of these outcome options. 23
A quick note about categoricals and exemptions as they relate to the MDS. If a person receives a categorical or exemption determination on their Level I, this is considered Level II activity, even though it happens without a Level II assessment. When completing the MDS at the NF, make sure the presence of a PASRR condition is indicated. Many providers incorrectly document this. 24
When should you submit a Level I? The name says it all: PASRR: Pre admission screening you will submit the level I before admission. Ascend encourages you to begin discharge planning as soon as possible. If you think the person might need NF placement, submit the Level I. It is good for 60 days after completion with a few exceptions. This prevents delays in discharge if the person needs a level II. Resident Review you will submit the Level I if the person has an expiring short term approval/time limited stay or has a significant change in status. Important Reminder In Iowa, PASRR was linked to payment as of 2/1/16, via the PathTracker Plus system, which has been available to NFs since 2/1 of 2015. This system helps Iowa Medicaid track PASRR compliance with preadmission and helps insure more efficient transfer of information and faster and more accurate Medicaid payments to NFs. NFs are expected to enter 100% of their residents into the PathTracker Plus system and use PathTracker for all discharges and transfers. Coming soon PathTracker will also address other level of care changes! 25
Vast majority of PASRRs are not Level II. 12.5% of all Level I referrals identify a Level II condition. Of those, 1046 receive a full LII evaluation, comprising 7.7% of all LI referrals. 26
Tuesday is busiest day. Friday is 4 th busiest day. 27
Peak time is 7am which is plenty of time for a Level I decision. Providers are good about getting referrals in early, which leaves plenty of time for a decision. 28
29
We average about 12 calls each day and fewer than 5 emails (1 3 on average) every day. Our average response time is about 4 hours for both calls and emails. For the fastest response time, be sure to contact the helpdesk directly. There are several factors that can influence response time from Ascend. First, is contacting someone other than the helpdesk. If you leave a VM for a specific clinician or other Ascend staff member, we do our best to respond within 5 business hours, but that may not be feasible in all instances. Many times the members of our leadership team, clinicians, and ancillary teams are away from their desks for meetings or out of the office for extended time periods. For the fastest and most reliable response times, be sure to contact the help desk. 30
Brad Qualified assessors licensed MI or IDD professionals Conduct clinical interview with individual Speak with legal guardian, family, and support staff Review clinical record Document interview and give impression of interaction Must schedule time for interview prior to arrival Will call the referral source to do schedule Notify staff and individual that IC will be coming by IC will ask staff to sign attestation acknowledging process completed appropriately 31
A level II is an in depth assessment. Ascend conducts both MI and IDD assessments in Iowa. To conduct a Level II, the interviewer must meet and interview the person, review the medical record, and interview support staff. Ascend clinicians interview the person for about 45 minutes to an hour and ask questions on everything from the number of children the person has to what things/situations cause the person to experience an increase in psychiatric symptoms. We find out information about who the person is, what he likes or dislikes, what makes her happy or sad. We find out about the person s needs, diagnoses, and what the person wants for his or her life. Where she wants to live, who his support network is, and what will help her be successful in the NF and in a community setting. Although we believe this information is the only way to help the person live the life they choose to live, these are also state and federally required elements for a good PASRR assessment. 32
ICs do not have the authority to make determinations regarding assessment outcome, identified services, or length of stay. 33
The Level I helps us start to answer the 4 questions. The level II is where we get the really great answers. 34
Let s take a quick glance at the component chart again. We discussed the Level I, the next step is the L2.
After Ascend receives the completed Level II assessment, we review all of the information, including the medical record and supporting interviews, and our clinicians make a determination about the individual s psychiatric and medical stability, the need for NF care (meaning does the person meet medical necessity & LOC for NF placement), and what type of the services a person needs to be successful. We write all of that up in a summary of findings report and send a copy to the LI submitter. The NFs need to review this in detail before the person can go to their facility otherwise, how will they know if they can deliver the identified services and meet the person s needs? Federal regulations suggest an average of 7 9 days for the completion of the entire PASRR process, although contractually, Ascend has 5 calendar days. We average 5 calendar days. Providers can greatly influence the timeliness of LII reports by responding to questions promptly and submitting requested information at the time of submission of the Li screen. 36
Here are the Level II outcomes you could see on assessments/in the system. Let s talk about what each of these means for you. 37
Here are the Level II outcomes you could see on assessments. Let s talk about what each of these means for you. 38
Of the total L1 submitted, of the people who went to NF, how many had SS identified? This slide shows the % of Individuals approved with Specialized Services, those approved without Specialized Services, those who were ruled out of PASRR population, and those who received a LOC or Specialized Service denials. 39
If you would like to request a reconsideration on the Level II outcome, you have 10 calendar days to do this. You must send a written request that includes the reason for the request and has additional information that was not considered during the original L2 but was available prior to the PASRR SOF date. You can fax or email this request to us and we have 5 calendar days to complete the review of the new information. Remember, a reconsideration does not guarantee you will receive the outcome you are requesting. Please remember short term approvals are not appealable. Reconsideration and appeal language and instructures are included in every Level II decision. 40
Since July 2016, we have had over 30 thousand Level I screens submitted. Almost 2000 of those were referred for Level II during that time. Of those Level II screens, 108 had a delayed outcome. there were 108 assessments with a delayed outcome, here are the reasons for the delay. In combination with LII TAT data: we do a good job of being on time. sometimes we have delays some of these are due to tardiness, missing information, or difficulty scheduling the assessment. However, in many cases, we are waiting on documentation from the submitter to complete the level II. 33 screens of the 108 late determinations from July 2016 through February 2017 were caused specifically by the absence of an H&P from within the past year. It is a federal requirement that the information available on the H&P be incorporated into the Level II Summary of Findings. While the state may not have requirements about how often a H&P is required, federal regs require this information to be less than a year old. Of the 33 that were late because of H&P, 13 screens were cancelled because we never received the H&P. 8 of the 13 cancelled screens were resubmitted for determination. 41
Over the next few slides, we will discuss the purpose of Status Changes and what to do if you have an old PASRR on record. 42
Referral for Level II Resident Review Evaluations Is Required for Individuals Previously Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances: Note: this is not an exhaustive list A resident who demonstrates increased behavioral, psychiatric, or mood related symptoms. A resident with behavioral, psychiatric, or mood related symptoms that have not responded to ongoing treatment. A resident who experiences an improved medical condition such that the resident s plan of care or placement recommendations may require modifications. A resident whose significant change is physical, but with behavioral, psychiatric, or mood related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living. A resident who indicates a preference (may be communicated verbally or through other forms of communication, including behavior) to leave the facility. A resident whose condition or treatment is or will be significantly different than described in the resident s most recent PASRR Level II evaluation and determination. (Note that a referral for a possible new Level II PASRR evaluation is 43
required whenever such a disparity is discovered, whether or not associated with a SCSA.) 43
Referral for Level II Resident Review Evaluations Is Also Required for Individuals Who May Not Have Previously Been Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances: Note: this is not an exhaustive list A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where dementia is not the primary diagnosis). A resident whose intellectual disability as defined under 42 CFR 483.100, or related condition as defined under 42 CFR 435.1010 was not previously identified and evaluated through PASRR. A resident transferred, admitted, or readmitted to a NF following an inpatient psychiatric stay or equally intensive treatment. 44
We know the font is really small here, and the point isn t for your to read this content on the slide. We wanted to show you that there are SC instructions in the MDS 3.0 45
As always, the group that knows the individual best should submit the Level I to start the status change process. In most instances, this is the nursing facility. If the person has been hospitalized in a psychiatric unit, the NF may request the psych hospital complete the Level I and Level II to ensure psych stability prior to return to the NF; however, the NF can complete the Level I following the individual s return. 46
The process to initiate a status change is simple. Submit a new Level I to get the process started. If, after reviewing the submitted information, our clinicians determine the person requires a L2, we will complete that process and develop new PASRR identified services. If the person doesn t require a Level II, continue using the same PASRR identified services that are already in place. 47
Let s talk about PathTracker Plus 48
Only providers in NF can access PathTracker. The purpose of PathTracker is to manage your census to ensure proper payment from IME. IME confirms the PASRR information is accurate when processing payment. This means you MUST report admissions, transfers, discharges, & deceased residents in a timely manner. This does not mean immediate, but within a few days is great. We encourage you to make this a standard part of your admission/discharge paperwork process. If other staff from your facility need access to the Ascend system to complete these notices, that is fine. Anyone who needs access can have it, simply ask them to work with your facility s web supervisor to get signed up and learn how to use the system the right way. Resources are also available on PASRR.com. 49
PathTracker is very simple to use. We find that when people have questions, it is often because they want it to be more complicated than it is. You can see here an example of how to complete an admission notice. This is an excerpt from the PathTracker user guide, available on PASRR.com. This guide walks you through each step of the process. Quick note, this is not a real person 50
Here is an excerpt from user guide, available on PASRR.com, for submitting discharge notices. When completing the notices, be sure to use the PASRR date from the record, even if it is an old one. As a matter of fact, if the PASRR that you have is older than 9/1/2011 and as such, doesn t appear in the Ascend system, then it is even more important that you enter all records for these individuals as we otherwise have no means of tracking whether that individual has a PASRR and they may appear to have compliance issues. 51
This shows that we had 2153 new admissions reported in PathTracker from 3/1/15 9/30/16. Within those admissions, 131 people/6% transferred to alternate NFs and 1164 people/54% discharged. That is just over half of the admissions during that time also discharged. Most returned home (46%). Some went to the hospital (38% total, either psych or medical) and others (about 16%) went to an alternate location these are often group homes, ALFs, or to live with family members. 52
Next, let s talk about PASRR identified services 53
PASRR Rehabilitative services, or Rehab services, are those services that the NF is responsible for providing as part of their rate. Often referred to as services of lesser intensity, these are services that are general to individuals with MI/ID/RC. They are called lesser intensity because they are services less intense than those of specialized services. Although they are less intense, they must still be incorporated into the individual s plan of care. Specialized services play a critical role in PASRR. These services are unique to the person and serve to meet this person s specific disability needs. They must be delivered by a disability expert and are above and beyond what the NF typically provides. The state is responsible for any associated cost, although the NF must coordinate, arrange, and ensure service delivery. Community Placement Supports are unique to the person to assist with transition to community based living. Identified to assist with discharge planning to ensure a successful transition, when appropriate. 54
Some examples of common Rehab services. These services do not require delivery by a specific type of professional anyone can record symptoms and help keep everyone safe. This is not an exhaustive list, only some examples you might commonly see. 55
Iowa PASRR Specialized Services Updated: July 2015 The following list includes all PASRR Specialized Services to be listed in the Ascend PASRR Summary of Findings, for identification and use with Iowa PASRR covered individuals: Specialized Services disability specific services for mental illness and/or intellectual disabilities/related conditions provided by a professional with behavioral health licensure or expertise Iowa PASRR Specialized Services: Acute Inpatient Psychiatric Treatment Initial Psychiatric Evaluation to determine diagnosis and develop plan of care The aims of a general psychiatric evaluation are 1) to establish whether a mental disorder or other condition requiring the attention of a psychiatrist is present; 2) to collect data sufficient to support differential diagnosis and a 56
comprehensive clinical formulation; 3) to collaborate with the patient to develop an initial treatment plan that will foster treatment adherence, with particular consideration of any immediate interventions that may be needed to address the safety of the patient and others or, if the evaluation is a reassessment of a patient in long term treatment, to revise the plan of treatment in accordance with new perspectives gained from the evaluation; and 4) to identify longer term issues (e.g., premorbid personality) that need to be considered in follow up care. Ongoing psychiatric services by a Psychiatrist or Psychiatric ARNP to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders and to evaluate ongoing need for additional behavioral health services Ongoing follow along care provided by the above professions to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders and to evaluate ongoing need for additional behavioral health services Ascend identifies the Rehab Service of Obtain archived psychiatric records to clarify history and to provide to behavioral health service providers with this Specialized Service to ensure continuation of care Individual Therapy by a licensed behavioral health professional (may include Mobile Therapy) A process through which Individuals work one on one with a licensed behavioral health professional to explore their feelings, beliefs, or behaviors, work through challenging or influential memories, identify aspects of their lives that they would like to change, better understand themselves and others, set personal goals, and work toward desired change Group Therapy by a licensed behavioral health professional A form of psychosocial treatment lead by a licensed behavioral health professional where a small group of Individuals meet regularly to talk, interact, and discuss problems with each other and the group leader licensed behavioral health professional ). Group therapy attempts to give Individuals a safe and comfortable place where they can work out problems and emotional issues. Individuals can gain insight into their own thoughts and behavior, and offer suggestions and support to others. In addition, Individuals who have a difficult time with interpersonal relationships can benefit from the social interactions that are a basic part of the group therapy experience. Neuropsychiatric evaluation by a neurological and behavioral health professional Neuropsychiatry is the practice of treating behavior and psychological effects 56
that are associated with either neurological diseases or injuries to the brain. Generally, neuropsychiatric evaluations help to diagnose a patient with the right medication that will help them to recover, or at the very least, assuage any immediate and detrimental effects. Individuals who suffers from any psychological and other related conditions such as head injury, epilepsy, attention deficit hyperactivity disorder, irritability, dementia, or any other organic mental disorder may benefit from this evaluation. Clinical neuropsychiatric/psychiatric evaluations are can be performed by neurologists, neuropsychologists, psychiatric and medical advanced practice nurses, and behavior analysts. Assessments are comprehensive, and include a discussion of the presenting problems and concerns; review of past medical, neurological, neuropsychiatric and educational difficulties and issues; abstraction of pertinent past medical and other records; complete physical, neurological and mental status examination; discussion concerning our clinical findings and diagnostic impressions; suggestions for further diagnostic testing; outline of treatment recommendations; and a comprehensive written report. Evaluations can determine whether a behavior is occurring for a reason such as attention, getting access to a preferred item, wanting to avoid performing a task or demand; or whether the behavior is being biologically/automatically driven and not under the individual s control. 56
Psychological Testing for differential diagnosis, resulting in appropriate treatment plan revisions and services Conducted by a Psychologist for making differential diagnosis of all psychiatric conditions and comprehensive treating planning. May be particularly useful when presentation is complicated or if previous treatment has failed. A functional assessment of maladaptive behaviors by a behavior analyst or qualified behavioral health professional with equivalent experience The process of determining the cause (or function ) of behavior before developing an intervention for behaviors that are causing disruptions This assessment will attempt to identify the events that control the display of problematic behaviors. The assessment will document the Antecedents, (what comes before the behavior), and Consequences (what happens after the behavior), by observing the individual in each environment where the problem occurs. A behaviorally based treatment plan to include both routine and crisis related 57
behavioral supports developed with assistance from a behavior analyst or qualified behavioral health professional with equivalent experience With the assistance from a behavior analyst or behavioral health professional and after the completion of a functional assessment, the behaviorally based treatment plan is a plan that staff will consistently implement in response to the Individual s behaviors. Development, by the individual, of a Behavioral Health Advanced Directive (such as a Wellness Recovery Action Plan, WRAP), with support and assistance from a Certified Mental Health Peer Support Specialist or other appropriately trained behavioral health professional With the assistance of a Certified Mental Health Peer Support Specialist, the Individual is able to express their preferences on where to receive care and what treatments they are willing to undergo. They are also able to identify an agent or representative who is trusted and legally empowered to make healthcare decisions on their behalf. These decisions may include the use of all or certain medications, preferred facilities, and listings of visitors allowed in facility based care. Wellness Recovery Action Plan (WRAP) is a self designed prevention and wellness process that anyone can use to get well, stay well and make their life the way they want it to be. A WRAP accomplishes the following (1) Help the Individual discover their own simple, safe Wellness Tools, (2) Develop a list of things the Individual can do every day to stay as well as possible, (3) Help the Individual identify upsetting events, early warning signs and signs that things have gotten much worse and, using Wellness Tools, develop action plans for responding at these times, (4) Guide the Individual through the process of developing a Crisis Plan or Advance Directive, and (5) Introduce the Individual to Post Crisis Planning Peer Support Services, delivered by a Certified Mental Health Peer Support Specialist Peer Support Services are delivered by a Certified Mental Health Peer Support Specialist who has a personal experience as well as training in recovery from mental health, substance use, or trauma conditions who guide and support others who are experiencing similar concerns and encourage them towards increased wellness. Peer Support Services include sharing of experiential knowledge, skills, social learning, advocacy, help access community resources, provide information, and instill hope. Peer Support Services are offered in community mental health centers, recovery centers, veteran s service centers, workforce centers, and Integrated 57
Health Homes. Peer Support Services may be offered in an individual or group setting. Other Disability Specific Service: Please describe; Ascend does not identify this packaged service any longer, the Ascend QCs will identify the components of this service as appropriate. 57
The Community Placement Supports fall into these categories. These will be identified for everyone because the goal of PASRR and Olmstead is to ensure we consider what a person will need to be successful in the least restrictive environment; however, not everyone will need their CPS incorporated into their care plan. If a person has the potential for discharge or is requesting to return to a community setting, these are the types of services and supports that would be needed for a successful transition. 58
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This CMS LTC reform reforms the requirements in the conditions of participation for LTC Facilities So sometimes called New conditions of participation. Also, sometimes called final rule or new rule revisions were made on the proposed rule. This new rule for LTC reform is compared to the last major NF reform 1987 OBRA Regulations Implemented in 1991 The date of the New Rule for LTC reform is October 4, 2016. A motivation for the reform is to address the increased # and complexity of SNF care a key component is the behavioral health services regulations. A target to reduce hospital readmission, including behavioral health readmissions is sought by improving quality of life through delivery of needed services and a competency based workforce. Similar to OBRA regulations there is a phase in process. The handout has more details on regulation changes. [Concerns about challenges in meeting requirements and enforcement of details may result in major unintended consequences detail excessive in some areas: IPCO; behavioral health professional; Training requirements joint training for surveyors and providers, allowing more center focused approach based on specific environment/patient or resident population] 60
From the rule: In addition, the number of individuals accessing SNF care has increased and the health concerns of individuals residing in LTC facilities have become more clinically complex. These factors demonstrated a need to comprehensively review the regulation and informed our approach for revising the regulations. The following discussion highlights our approach for revising the LTC regulations as well as some of the most significant revisions set forth in this final rule. We have taken a competency based approach that focuses on achieving the statutorily mandated outcome of ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well being. As discussed in further detail, we are requiring facilities to assess their facility capabilities and their resident population. This competency based approach is compatible with existing state requirements and business practices, and promotes both efficiency and effectiveness in care delivery. 60
Require person centered care plan expanded resident assessment process Expand resident rights Require discharge planning process and plan for all residents Behavioral health services PASRR incorporated into assessment, care plan and discharge plan Expand medication review process to include more drugs Restrictions for pre Arbitration agreements and rules for prearbitration agreement 61
The new regulations put PASRR on the table more than ever before. As you can see here, many of the themes in the new rule align nicely with PASRR. PASRR can help NFs comply with these conditions of participation and serve individuals with disabilities well. Many of the keys to this have been right there all along within PASRR s processes and outputs. 62
PASRR addresses staff competencies necessary for level/ types of care needed for the resident PASRR identify topics for training programs to be documented in facility assessments. Behavioral health training correlates with resident s needs based on the facility assessment 63
First up, let s spend some time talking about PASRR compliant care plans 64
We have talked quite a bit over the past year or so about what a PASRR compliant care plan includes. There are several resources available to you, if you wish to use them. The main points to remember are that that the care plans must incorporate 4 elements: 1. Name the provider of PASRR identified services 2. Start date of services 3. Anticipated frequency of services 4. Anticipated duration of services And, they must incorporate every single PASRR identified service, including community placement supports, when appropriate. 65
This process involves an in depth review of the care planning efforts and the delivery of PASRR identified services by the NF and whether they appear to be meeting the needs of the individual. It is important to understand that even though the current process is being developed to review ONLY those individuals for whom Specialized Services are identified in PASRR, the expectations and federal regulations for PASRR compliant care planning do apply to ALL individuals with a LII PASRR. ServiceMatters has four goals: 1. Measure and report care plan compliance and service delivery of all PASRR identified services 2. Identify residents with potential for discharge 3. Measure and report on gaps in availability of PASRR identified services and/or providers in communities 4. Evaluate changing needs of each person by reviewing the PASRR Identified Services, approved time periods, and other needs 66
We complete this review by requesting a copy of the care plan as soon as 21 days after the Level II determination. After Ascend requests the information, you have 7 days to respond. We will send a second/final notice if you fail to respond to the first request. Remember, regardless of when Ascend makes the request for the Care Plan, IA requires that Care Plans be developed within 21 days of admission. We will request the care plan and also request supporting documentation through the web system. 67
Let s quickly review the important points of completing a ServiceMatters review: 1. Look for your inbox notice in the navigation menu 2. Respond to notices within 7 days 3. Complete the form, Upload the PASRR compliant care plan, and Upload requested supporting documents 4. Respond to any questions from Ascend s analyst for clarification 5. Address any compliance issues identified in the notification of findings 6. Participate in the Technical Assistance webinars with DHS 68