1960s and 1970s deinstitutionalization

PASRR FOR PROVIDERS North Dakota, 2012 PASRR History 2 Began with Federal Nursing Home Reform Law: OBRA 1987 PASRR is federally mandated for every person entering or residing in a Medicaid certified NF PASRR screens for disability, identifies needs, issues recommendations NFs must assure that PASRR recommendations are addressed 1

PASRR Laws in Historical Context 3 1960s and 1970s deinstitutionalization Downsized psychiatric i hospitals Few community treatment resources were available Led to trans-institutionalization Elderly persons in psychiatric hospitals declined ~40% Persons with MI in NFs increased by 100% Widespread use of chemical restraints/significant under-treatment of psychiatric conditions 4 Nursing Home Reform OBRA 1987 NF responsible to treat the whole person, not just medical or functional needs Emphasis on the individual s quality of life NFs responsibility to meet psychological needs of residents increased Prohibited inappropriate use of medication restraints and antipsychotics 2

PASRR Components Required by OBRA 87 5 Level I (disability screen) Every admission to Medicaid certified NFs Asks whether there is any suspicion of disability Level II (comprehensive evaluation) Makes placement and treatment recommendations Report and notifications NF must address recommendations and keep in chart Adverse decisions may be appealed Follow-up PASRR assessments NF residents continue to be monitored for placement and treatment appropriateness Federal PASRR Goal 6 To ensure that nursing facility applicants and residents with serious s mental illness and/or intellectual and developmental disability are: Identified Placed appropriately, least restrictively Admitted or allowed to remain in a particular NF only if they can be appropriately served there Provided with the disability services they need, including specialized rehabilitative and specialized services 3

WHY IS PASRR IMPORTANT? Importance of Screening for Disability 8 When an underlying disability remains unrecognized or untreated, it can impact: A person s longevity, A person s quality of life, A person s likelihood of regaining independence, The safety of other residents 4

9 Importance of Comprehensive Evaluation Opportunity to identify unique needs of each person Assure that the most appropriate placement options are considered Identify interventions to improve quality of life while in an NF Identify potential for over or under-use use of psychotropic medications Identify strategies to assure the safety of other residents WHAT WE HAVE LEARNED About Disability in NF Settings 5

11 Presence of Mental Illness in Nursing Home Residents Over 560,000 NF residents have mental illnesses, (other than dementia) Versus 51,000 in psychiatric hospitals (Grabowski, Aschenbrenner, Feng, & Mor, 2009) NFs serve far more persons with mental illness than all other health care institutions combined Persons with MI who admit to NFs tend to be younger and to stay longer Mental illness is not an uncommon factor driving NF placement (Timmel, 2009) Findings from NF Studies 12 Only 20% of NF residents with an identified psychiatric disorder saw a mental health specialist (Shea, et al., 1994) 78% of NFs experience barriers to residents receiving needed MH services (OIG, 1996) Barriers include geographically underserved areas, stigma, staff unawareness, and under- or mis-diagnosis 55% of residents have unmet MH service needs among those referred for evaluation (Borson,et al., 1997) 90% of state Medicaid programs cover only basic psychiatric consultation in NFs (Linkins, et al., 2006) 6

Mental Health Treatment in NFs 13 1992 50 state survey of Medicare & Medicaid-Certified NFs (Lombardo & Sherwood,1992) 46% MH specialists resistant to serve NH residents 53% difficult to obtain psychiatric services 1998 Survey (Reichman, et al., 1998) Same findings Problems more difficult in rural and small facilities 75% of facilities: consultation on non-pharmacological interventions and staff education are inadequate 2007 Survey of NFs (SAMHSA, 2007) 50% cited lack of resources to provide or obtain MH services & under-staffing difficulties 50% reported reluctance among community professionals to treat NF residents Only 20% offered care team meetings for mental health treatment or quality review of treatment performance The result: Unmet MH needs 14 80% of NF residents with MI did not receive services from MH professional (Shea et al., 2000) Front-line NF staff receive little training in detection, treatment, and management of MI (Beck et al., 2002; Mercer et al., 1993) 20% of NFs receive survey deficiencies each year for MH care (Castle et al., 2001) 7

15 The Cost of Not Recognizing Treatment Needs She s so sweet, she s never a bit of trouble. Ms. Smith, age 70, diagnosis: Major Depression He makes me a little nervous because he talks to himself and waves his arms when I come into his room to get him dressed. I get stuff done quickly and get out of there. Mr. Watts, age 65, diagnosis: Schizophrenia She s always stirring stuff up. She got mad the other day and said horrible things about her staff. She only likes one person here. The rest of us have a hard time assisting her. Ms. Burke, age 54, diagnosis: Depression and Borderline Personality Disorder Lessons Learned 16 MH services in NF settings are imperative Training for nursing home staff, especially with high turnover is essential. NFs can leverage PASRR to identify and address MH needs Partnerships between NFs and MH specialists are crucial 8

17 Effectiveness of MH Services for NF Residents Residents with psychiatric disorders who received treatment by a mental health specialist: Had a 26% lower mortality rate Showed significant decline in inappropriate antipsychotic use Staff training Improved staff knowledge and performance Reduced staff turn over Suicide by Elders 18 Highest risk group for suicide - 13% of the population, but 25% of all suicides; 85 years and older is twice the overall national rate. Two-thirds were in relatively good physical health when they died. 20% have been seen by a MD within 24 hours of committing suicide; 41% were seen by a MD within a week; 75% within a month; and 80% within 6 months. 66%-90% have at least one psychiatric diagnosis 2/3 of these are single episode clinical depression. 9

19 More that We ve Learned about NF Residents with Serious Mental Illness Persons in NFs are less likely to attempt suicide But have high levels of suicidal ideation Many die from indirect suicide; self-destructive behaviors such as: refusing to eat or not agreeing to lifesustaining medications (Thibault, 1999; Schmidt, et al.,1994) Ella (1936-2008) 10

21 Best Practices in Models of NF-Based MH Services what to look for: Multidisciplinary Team Model Expertise and Qualifications in Geriatric Psychiatry Individualized Assessment, Treatment Planning, and Follow-up Collaborative Treatment Planning between Consultants and Nursing Home Staff Staff Education in Identification and Management of Mental Health Problems WHAT WE HAVE LEARNED About U.S. trends 11

Gray Tsunami 23 By 2030, 20% of our population will consist of people age 65 and older One in six of these will have a primary psychiatric diagnosis More people than ever will need NF level services Therefore the need for support and services will continue to increase As will the number and the proportion of residents with significant MI and other disabling conditions Older Persons with SMI 24 Persons with mental illness die 25 years earlier on average (NASMHPD, 2006) For persons with SMI, the average life expectancy is 53 years Often due to poorly managed chronic medical conditions Often requiring support at younger ages 12

Causes of Morbidity 25 While suicide and injury account for about 30-40% of excess mortality, about 60% of premature deaths in persons with schizophrenia are due to natural causes (NASMHPD, 2006) Cardiovascular disease Diabetes Respiratory diseases Infectious diseases Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts 1998-2000 Rates per 100,000 40 35 30 25 20 15 10 5 0 DMH 2.2 RR MA 1.5 RR 4.9 RR 3.5 RR 25-34 35-44 45-54 55-64 26 (NASMHPD, 2006) 13

Smoking and Mental Illness 27 Prevalence=75% Consume 44% of all cigarettes nationally Smoke heavier Smoke more efficiently 28 Missed Opportunities are Common for Persons with Mental Illness Looking at a group of persons with serious mental illness, investigators found that: 88.0% who had dyslipidemia 62.4 % who had hypertension 30.2% who had diabetes WERE NOT RECEIVING TREATMENT (Ha, et al., 2006) 14

FEDERAL DISABILITY ADVOCACY Seeking more community services for persons with disability Deinstitutionalization Version II 30 1990 Americans with Disabilities Act 1999 Olmstead decision in Georgia 2001 New Freedom Initiative 2003 Money Follows the Person Grants 2009 The Year of Community Living Expansions of Home and Community Based Services Waivers Home and Community Based Services State Plan Option 15

31 Institutions and Disability: Federal Targets The overuse of institutions for placement of persons with disability violates Olmstead requirements and the Americans with Disabilities Act Unnecessarily institutionalizing persons with disabilities Failing to serve people in the most integrated setting Segregation of persons with disability in NFs is discrimination unjustified isolation, we hold, is properly regarded as discrimination based on disability 32 Federal Agency Partnerships in Promoting Community Living Department of Justice (DOJ) Involved in lii litigation i in fd federal courts in more than 20 states to enforce Olmstead Targeting state psychiatric hospitals, developmental disability institutions, adult homes and nursing facilities Departments within Health and Human Services CMS, Civil il Rights Division, i i SAMHSA, Housing 16

Federal PASRR Target: 33 Use PASRR to create seamless transitions from NF recuperative care to community placement 40% of NF residents with serious mental illness preferred placement in a community setting Clinicians judged community to be the most appropriate for ½ of NF residents with serious mental illness (Bartels, et al, 2003) Combining Lessons Learned 34 Disproportionate numbers of NF populations have mental health conditions or intellectual or developmental disabilities NF residents are among the most vulnerable of all populations The NF population is growing exponentially, as are residents with disabilities Services for residents are sometimes unavailable or inadequate Services to residents make a substantial difference in mortality and quality of life Federal aim is to transition persons to placement in the community with supportive services whenever possible 17

NORTH DAKOTA PASRR COMPONENTS: THE LEVEL I SCREEN PASRR Level I: Screen for Disability 36 The Level I is a universal screening for disability Typically completed by hospitals referring to NF Completed for everyone admitted to a Medicaid certified nursing facility Used to determine presence or suspicion of mental illness, Intellectual Disability (ID), or a Developmental Disability (DD) If there is a possible disability, a PASRR Level II evaluation must occur 18

Components of the Level I Screen 37 Demographics Indicators of possible mental illness Diagnoses or symptoms History of psychiatric treatment Dementia questions Psychotropic medications Indicators of possible intellectual or developmental disability Requests for an exemption or a categorical decision Guardianship information and signature Logistics of the Level I Screen 38 Level I screens are prioritized according to the time of submission reviewed within 6 business hours of submission A copy of the completed Level I screen and LOC determination letter will be given to the admitting facility This letter and the Level I screen must be maintained in the resident s medical record at all times A copy must be transferred with the individual id if she or he moves to another NF. A positive Level I means there is suspicion of disability and PASRR Level II assessment must be done 19

To Learn More 39 To learn about how to submit a web-based Level I screen in North Dakota go to www.pasrr.com. Here you will find: A tutorial, which provides you with a tour of the system A Provider Manual with PASRR Level I Screening Instructions and ND Medicaid Level of Care Instructions You can also print a copy of the PASRR Level I form questions 40 LEVEL OF CARE FOR LONG TERM CARE SERVICES Explanation & Intent for Nursing Facilities and Hospitals 20

Purpose 41 Determine necessity of nursing facility or swingbed placement Medical Need Medicaid or pending Medicaid pay source How to Submit 42 Login at www.pasrr.com Enter Referral Select Referral Type (LOC and/or PASRR) Select LOC Type (NF or Swingbed) Provide details Only mark medical info that applies Fax supporting documentation Save for up to 24 hours Submit to Ascend 21

Using the Web-System 43 www.pasrr.com (North Dakota) Obtaining Log-on on & Password Privileges 44 Access provided by agency supervisor Supervisor maintains login information 22

Agency Web-Supervisor for PASRR.com 45 Supervisor registration www.pasrr.com Select ND Web-Based PASRR/LOC System Select supervisor registration (under supervisor tools) Ascend forwards email within 2 days which includes access decision and link Supervisor establishes password and signs user agreement Agreement confirms supervisor will maintain users - Adding and removing staff from web-access See Getting Started for Supervisors at www.pasrr.com Supervisor adds/removes users Logging On 46 Enter your unique name and password and note user agreement attesting information accuracy 23

Logging On 47 Choose no passwords should never be saved on the computer Completing a Screen 48 Log on Enter user name and password View activity page (all screens for prior 2 weeks) Select referral type or submit tracking Complete all sections of the form with detailed information Once complete, press submit 24

LOC Form - Page 1 49 LOC Form - Page 1 50 25

Criteria and Supporting Information 51 A C B D SECTION A CRITERIA Any one of the following may demonstrate that nursing facility level of care is medically necessary. 26

A.1 53 The individual s nursing facility stay is or is anticipated to be temporary for receipt of Medicare Part A benefits. A nursing facility stay may be based on this criterion for no more than fourteen days after termination of Medicare Part A benefits. A.1 Means 54 Approval is good only for 30 days Additional days require additional screening using other criteria 27

A.2 Comatose State 55 The individual is in a comatose state A.2 Means 56 Coma Clinical i l state of unconsciousness Unaware of self and environment Persistent Vegetative State Wakeful but devoid of conscious content No cognitive or effective mental function 28

A.3 - Ventilator 57 The individual requires the use of a ventilator at least t66 hours per day, 7 days per week. A.3 Means 58 Use of mechanical ventilator At least 6 hours per day 7 days per week Does not apply to CPAP or BiPAP 29

A.4 Respiratory Problems 59 The individual has respiratory problems that require regular treatment, observation, or monitoring that may only be provided by or under the direction of a registered nurse or in the case of a facility which has secured a waiver of the requirements of 42 CFR 483.30 (b), a licensed practical nurse and is incapable of self care. A.4 Means 60 Many methods of care Combined assessment of Treatment needs Capability for self-care 30

For the Review 61 Information Diagnosis Etiology/Cause Treatment provided Who provides treatment Anticipated needs Limitations to self-care ability Sources Respiratory therapy notes History and physical (H&P) Home health notes Nursing notes Descriptive Information for A.4 62 Individuals who meet LOC based on this criterion: Example 1: Has diagnosis of emphysema. Requires IV steroids for 4 weeks. Example 2: Has diagnosis of COPD. Uses oxygen or nebulizer treatments during the day, but due to stroke, is unable to understand how and when to use them. Lives in community with little outside support. Individuals who do not meet LOC based on this criterion: Example 1: Has diagnosis of COPD for the past 2 years. Uses inhaler daily. Needs no assistance with inhaler. Example 2: Has diagnosis of asthma. Independent with daily nebulizer treatments and inhaler. These are only a few examples of many possibilities. 31

A.5 Activities of Daily Living 63 The individual requires constant help sixty percent or more of the time with at least two of the activities of daily living of toileting, eating, transferring, and locomotion. For purposes of this subdivision, constant help is required if the individual requires a caregiver s continual presence or help, without which the activity would not be completed. A.5 Means 64 Physical presence of a caregiver Constant instruction or cueing Hands-on physical assistance Does not include set-up 60% or more of the time At least two ADLs Toileting - use of commode, bedpan, or urinal; cleansing; clothing adjustment; etc Eating physical assistance with feeding constant Eating - physical assistance with feeding, constant cueing/prompting, etc Transferring - movement from surface to surface such as bed to chair, chair to wheelchair, etc Locomotion - movement between locations, such as room to room 32

A.6 - Aspiration 65 The individual requires aspiration for maintenance of a clear airway. A.6 Means 66 Deep suctioning Removal of secretions from the airway Not just within the cannula but into the trach Can include someone who has a tracheostomy or a breathing tube inserted through the nose or mouth and into the trachea Does not include suctioning or swabbing of the mouth 33

A.7 - Dementia 67 A.7 Means 68 Dementia is the development of multiple cognitive deficits that include: memory impairment and at least one of the following cognitive disturbances aphasia - deterioration of language function apraxia - impaired ability to execute motor activities despite intact motor abilities & sensory function disturbance in executive functioning - impaired ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior 34

For the Review 69 Physician-diagnosed dementia occurring at least six months prior to the screening or, In the absence of a diagnosis, evidence supporting the presence and progression of dementia. Evidence must support the need for a professionally staffed environment and includes: Descriptions of behaviors (e.g., agitation, uncooperativeness, impaired sleep, confusion, difficulty with changes in routine) Deficits (e.g., memory difficulties, etc) Documentation to describe if the dementia has interfered with social or occupational functioning the extent of that interference evidence that may support or rule out a nonorganic mental disorder (such as Major Depression) accounting for the cognitive impairment SECTION B CRITERIA In the absence of meeting any one criterion in Section A, NF level of care may be determined medically necessary if any two of the following criteria i are met. 35

B.1- Medication Administration 71 The individual requires administration of prescribed Injectable medication, i Intravenous medication or solutions on a daily basis, or Routine oral medications, eye drops, or ointments on a daily basis. B.1 Means 72 Type of assistance Set-up Physical administration Frequency of assistance Medications prescribed for daily use Psychotropic Medical Consideration of physical and cognitive abilities 36

B.2 73 The individual has one or more unstable medical conditions requiring specific and individual id services on a regular and continuing basis that can only be provided by and under the direction or a registered nurse, or in the case of a facility which has secured a waiver of the requirements of 43 CFR 483.30 (b), a licensed practical nurse. B.2 Means 74 Individualized evaluation of symptoms Fluctuations in lab values, vital signs, and levels Medication dosage adjustment based on symptoms such as weight change, swelling, shortness of breath Medication dosage adjustment based on vital sign changes Increased frequency of doctor visits Concurrent diagnoses Limitations to self-monitoring of condition Information from family members and caregivers 37

B.3 75 The individual is determined to have restorative potential and can benefit from restorative e nursing or therapy treatment, such as gait training or bowel and bladder training, which are provided at least five days per week. B.3 Means 76 Potential to regain lost skills Rehabilitation services Physical therapy Occupational therapy Speech therapy At least 5 days per week Routine maintenance services (e.g., range of motion exercises) are considered part of everyday care and are not restorative. 38

B.4 77 The individual requires administration of feedings by nasogastric tube, gastrostomy, jejunostomy, or parenteral route. B.4 Means 78 The individual receives nourishment via a gastrointestinal or intravenous tube. Either route of administration may require nursing intervention to monitor intake and output ( I and O ), residual results, and correct tube placement. 39

B.5 Skin Disorders 79 The individual requires care of decubitus ulcers, stasis ulcers, or other widespread skin disorders. B.5 Means 80 This criterion references skin disorders that have a potentially detrimental effect on an individual s overall physical health. For example, a decubitus ulcer that is not treated appropriately may quickly lead to serious complications. However, many skin disorders, while unpleasant, pose minimal i threat t to physical health (e.g., forms of dermatitis, acne, etc) and are not likely to require nursing facility level of care. 40

B.6 Activities of Daily Living 81 The individual requires constant help sixty percent or more of the time with any one of the activities ities of daily living of toileting, eating, transferring, or locomotion. For purposes of this subdivision, constant help is required if the individual requires a caregiver s presence or help without which the activity would not be completed. B.6 Means 82 Physical presence of a caregiver Constant instruction or cueing Hands-on physical assistance Does not include set-up 60% or more of the time Any one ADL Toileting - use of commode, bedpan, or urinal; cleansing; clothing adjustment; etc Eating physical assistance with feeding constant Eating - physical assistance with feeding, constant cueing/prompting, etc Transferring - movement from surface to surface such as bed to chair, chair to wheelchair, etc Locomotion - movement between locations, such as room to room 41

SECTION C CRITERIA The following may demonstrate that a nursing facility level of care is medically necessary only for individuals with restorative potential and residing at Dakota Alpha or receiving waiver services for restoration. C 84 42

C Means 85 Focus is on Potential for restoration or improvement Non-geriatric individuals with physical disabilities Not seeking medical care alone Not meeting criteria in Sections A or B Important to report Diagnosis Goals Progress toward goals Length of time progress is retained Types of rehab Frequency of services SECTION D CRITERIA The following may demonstrate that a nursing facility level of care is medically necessary only for individuals with acquired brain injuries. i 43

D 87 D Means 88 Acquired brain injury Direct supervision Oversight Prompts Cues Physical assistance At least 8 hours per day 7 days per week Describe supervision Type Frequency 44

LOC Form- Additional Comments 89 Example 1 90 45

Example 1 (continued) 91 Example 2 92 46

Example 3 93 Example 4 94 47

RETROSPECTIVE REVIEWS Applying for Medical Assistance while residing in a NF NF With a Retro Review: Retro process must be completed prior to submitting payment alert to STATE NF obtain approval from Medical Services Long Term Care Administrator using form SFN 114 Submit Retro to Ascend if indicated on SFN form with supporting documentation and copy of signed Retro request form. 48

Approved by Medical Services Long Term Care Administrator NF to indicate a retro date, which can be up to 3 full months prior to original LOC date Submit 5 days worth of supporting documentation to Ascend to support facility requested retro start date When Will I know Ascend has 48 hours from referral to LOC review determination Retro review will be approved or denied 49

Things to Remember 99 Providing detailed information about the individual s id entire clinical presentation will result in the most thorough clinical review. Call Ascend s review nurses with any questions: Monday-Friday 8am-5pm Central time 877-431-1388 ext 3320 NORTH DAKOTA PASRR COMPONENTS: EXEMPTED OR ABBREVIATED LEVEL II ACTIVITY 50

101 PASRR Exemptions & Categorical Decisions When a suspicion of disability is identified through the Level el I screen, there are 4 federal options that ND uses to allow NF admission without a full, onsite Level II evaluation. These typically occur as part of the Level I screen s workflow Federal Options in North Dakota: 102 2 PASRR exemptions Exempted Hospital Discharge: also called convalescent stay Primary Dementia and MI 2 PASRR categorical decisions Provisional emergency Provisional delirium 51

103 Exemption 1: Hospital Convalescent Discharges Criteria: Admission i to a NF from a hospital after receiving i acute medical care The admission is to treat the same medical condition treated at the hospital The attending physician has certified that the stay is unlikely to exceed 30 calendar days The individual meets NF Level of Care 104 Exemption 2: Primary Dementia with MI Invoked only when dementia co-occurs with serious mental illness and: Dementia is both primary and advanced The mental illness will not be the primary focus of treatment attention again Must clearly support that the dementia is so advanced that mental health services will not be beneficial If any doubt, a Level II evaluation must be conducted 52

2 PASRR Categorical Decisions in ND 105 These allow the state to decide, by virtue of the person fitting into a category, that: NF is approved, or, PASRR specialized disability services are not necessary Require a brief PASRR write up and notification letters 106 PASRR categorical decision: NF Approval due to Delirium The individual s cognitive status could not be evaluated ated as a result of delirium The provider is permitted up to 7 calendar days following admission to initiate the remaining assessment components This outcome requires a follow up Level I/LOC no later than the 7th calendar day following admission 53

107 PASRR categorical decision: NF Approval due to Emergency (Type I) The individual with Level II condition has an urgent or crisis need for NF and : requires a sudden and unexpected need for temporary placement, and; no other placements are available. The NF completes a Level I and LOC within 2 working days of the emergency admission Good for up to 7 calendar days, the facility must update the Level I and LOC by the 7th day If the individual does not meet NF criteria at this time, s/he must be discharged by the 7th calendar day from admission 108 Another Use for Level I Screening Forms When a PASRR individual approved short term will stay beyond the approved time Convalescent Care (30 day maximum approval) Emergency Type I (7 day maximum approval) Delirium (7 day maximum approval) decisions. Submit a Level I screen to notify Ascend Ascend will then complete a PASRR Level II evaluation Federally required for payment to continue 54

And One More 109 When an NF resident experiences a significant change in status, providers use the Level I form to request a PASRR Level II Status Change evaluation. We will talk more about PASRR Status Changes in the next section. NORTH DAKOTA PASRR COMPONENTS: LEVEL II ONSITE EVALUATIONS 55

The Goal 111 of PASRR is to optimize each idiid individual s placement success, treatment success, and the individual s quality of life 112 PASRR Level II: Comprehensive Evaluation If the Level I screen indicates a PASRR condition, and if an exemption or categorical does not apply, then the Level II evaluation must occur prior to admission. This is a federal and not a state requirement. Onsite assessment of MI, ID, DD status and needs Reviewed by Ascend s quality team and by MD/psychiatrist Makes written recommendations about placement and treatment or service needs Needed at admission and whenever a resident experiences a significant change in status 56

Logistics of the Level II Evaluation 113 Referral source provides H&P, drug history, physicians orders Ascend or Regional DD staff conduct onsite PASRR interviews MI: evaluation reviewed by Ascend clinicians and summary is completed by Ascend MD/PhD MR/DD: Regional DD Coordinator makes the final PASRR determination Final determination summary is sent to the individual/guardian, referral & receiving facility, PCP PASRR Level II Evaluations: 4 Questions 114 Does the individual meet the state s criteria for a PASRR target diagnosis? What is the most appropriate placement for this individual? What types of services are needed for the individual to be successful in the recommended placement? If NF is approved now, might this individual at some point be a candidate for transition to community services? What kinds of supports would help this individual successfully return to his/her community? 57

115 Level II Question 1: Confirming a PASRR Condition Exists Does the individual have serious mental illness? Does the individual have intellectual disability? Does the individual have a PASRR related condition, or developmental disability? 116 Does the Individual Have a Serious Mental Illness? The 4 D s Diagnosis i of a major mental illness. Not a primary or sole diagnosis of advanced dementia Duration: current episode, or major treatment episodes or significant disruption within the past 2 years Disability/disruption: active symptoms within the preceding 6 months with evidence of impairment, i for example in: interpersonal functioning, concentration/pace/persistence, or adaptation to change 58

117 Targeted Conditions for the PASRR Mental Illness Do Not Include. People with situational emotional reactions People prescribed psychoactive medications for non-psychiatric conditions People with co-morbid dementia and mental illness when the dementia is very late stage People with a diagnosis of dementia as the sole psychiatric condition 118 Does the Individual Have a Diagnosis of Intellectual Disability? PASRR Criteria: A measure of intelligence at least two standard deviations below the mean Limitations in two or more of the following adaptive functioning skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure and work Onset before age 18 Condition likely to be lifelong 59

119 Does the Individual Have a Related Condition/Developmental Disability? Impairments of adaptive behavior or general intellectual functioning and requires treatment or services similar to persons with MR Present before age 22 Expected to continue indefinitely Results in substantial functional limitations in 3 or more of the following major life activities: self-care; understanding and use of language; learning; mobility; self direction; capacity for independent living. Examples: autism, spina bifida, cerebral palsy, TBI if occurred before 22 nd birthday Level II evaluation: Question 2 120 What is the most appropriate placement for this individual? 60

Appropriate 121. For an NF to be considered appropriate: The individual must meet nursing facility LOC criteria* The individual s total needs, including disability needs, must be thought to be best met by placement in the NF Not too acute for NF Not unsafe for NF placement (due to the disability) NF can serve the individual s disability needs adequately *Level of Care (LOC) criteria measure whether an individual s needs meet medical eligibility criteria to receive Medicaid nursing facility services 122 Level II question 3: Does the individual have Special Service needs? 61

PASRR Special Service needs: 123 There are two kinds of needs every PASRR Level II must discuss: Specialized Rehabilitative needs NF is responsible to provide. Any range of services to promote the success of the individual s placement. Specialized Service needs The state is responsible for addressing these needs. These require specialized MH/MR/RC professionals to deliver. NF is not responsible to provide through their daily rate. States have leeway to define and interpret the definition of specialized services. 124 PASRR Specialized Service for Serious Mental Illness In ND specialized services for a person with mental illness means the person needs acute care in an inpatient psychiatric hospital What if Specialized Services for Serious Mental Illness are recommended for a resident on a Level II? The NF must give discharge notice and begin arranging transfer to inpatient psychiatric hospital The individual may appeal But if the individual is a danger to others, the NF must make others safe Sometimes there is a gap between: NF not appropriate and an inpatient hospital is willing to admit this resident 62

125 The PASRR Level II evaluation summary report: The individual s history and disability care needs The Level II evaluation decisions The Level II evaluation recommendations The state s obligation for specialized services The nursing facility s obligation for rehabilitative services The nursing facility s obligation for monitoring the individual s ongoing needs Level II Decisions 126 Approval: Appropriate for NF ongoing Approval: Appropriate for short-term NF stay Denial of placement in NF because does not meet minimum LOC standards Denial of NF placement because he or she requires specialized services which cannot be provided in an NF PASRR Level II halted, no recommendations written; no PASRR condition 63

PASRR HAS POWER TO IMPACT INDIVIDUALS BECAUSE IT REQUIRES NFS TO ADDRESS PASRR RECOMMENDATIONS IN THE INDIVIDUAL S CARE PLAN 128 What might PASRR rehabilitative service recommendations look like? Recommending NF monitor/record symptoms indicating impending psychiatric decompensation Naming of environmental adaptations that will help the individual manage more successfully Naming what the NF must do to ensure the safety of others Naming the intensity of psychotropic medication review needed Identify a medication history and likely successful psychotropic regimen Recommending skills training to increase the likelihood of successful transition to the community post-nf stay 64

129 Once an individual with a PASRR condition becomes a resident: Level I screen and Level II report must remain in the individual s id medical record while the individual id is a resident Admissions, transfers, discharges and deaths must be reported Temporary transfer to a hospital and back to the NF does not require another Level II Transfer to a psychiatric hospital and back would trigger a significant changes in status report (use Level I form) Level I & II summary reports 130 A copy must be transferred with the individual if s/he transfers to a different nursing facility Medicaid Certified NF What do you do if you are being audited and you do not have a resident s Level II summary report in your files? 65

131 Level II significant change in status evaluations Federally required Monitored by Survey and Certification Renewed emphasis since MDS 3.0 additions NF required to request PASRR change of status review to determine if a Level II evaluation should be initiated $$ can be recouped if PASRR change of status was indicated and NF did not request review 132 PASRR Significant change in status indicators: Found in provider manual at www.pasrr.com Any resident with PASRR condition whose behavioral, mood, or psychiatric related symptoms have not responded d to treatment t t Any resident with PASRR condition who experiences an improved medical condition, such that the plan of care or placement recommendations may require modifications. All residents demonstrating emergence of new symptoms or significantly increased behavioral, mood or psychiatric symptoms A resident whose condition or treatment is significantly different than described in the resident s PASRR Level II determination. A resident with PASRR condition i who was approved short-term and is expected to stay longer Following inpatient psychiatric stay to confirm appropriateness of NF, for a person whose Level II evaluation resulted in a decision requiring inpatient psychiatric treatment 66

North Dakota PASRR Statistics 133 Approximately 3770 Level I screens per year Approximately 110 Level II evaluations per year A significant percentage of Level II evaluations recommend ST stays 25 % of ND Level II evaluations recommend a short term NF stay because the person has potential for eventual community placement Only 1% of ND Level II evaluations determine that psychiatric hospitalization is required immediately More information 134 Access the Web Based PASRR Level I System by going to www.pasrr.com Provider manual Instructions on Level I and the Level of Care Tutorials are provided for your assistance Information about Level II evaluations 67

Contacts 135 North Dakota PASRR Authorities Dbbi Debbie Baier, Medical Services Division, i i dabaier@nd.gov Vicci Pederson, Disability Services Division, vpederson@nd.gov Ascend Level I: Connie Tanner, ctanner@ascendami.com Level II: Treva Marquis, tmarquis@ascendami.com Helpdesk: 877-431-1388, ND PASRR REAL STORIES, REAL PEOPLE Thinking about quality of life 68