Welcome to Ascend s PASRR training for Iowa PASRR Providers. The information in this presentation will provide an overview of the history and purpose of PASRR 1
Ascend, A MAXIMUS Company is an internationally recognized leader in healthcare management services. Our corporate headquarters 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. Ascend has been conducting PASRR assessments in Iowa since 2011 and we value the relationships we have built with you over the years. 2
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. 3
The legal responsibilities are very clear in PASRR federal rule. CMS is the federal authority responsible for publishing rules and guidance and auditing state PASRR compliance. The state Medicaid authority is responsible for state PASRR compliance. They set and approve PASRR policy, although they may grant another entity the rights to conduct PASRR activity on their behalf, as is the case with Ascend s contract in Iowa. The state mental health authority, which is the Iowa DHS Division of MHDS has oversight of MI Level II PASRR activity. They cannot do any assessments, but can make determinations and conduct write ups. In IA, the MH authority has granted Ascend the responsibility of conducting the MI Level II assessments, making determination, and developing the summary of findings with PASRR identified services. The state IDD authority, which is also the Iowa DHS Division of MHDS has oversight of IDD Level II PASRR activity. They can conduct assessments, make determinations, and develop the summary of findings with PASRR identified services. As with MI assessments, the DD authority has granted Ascend the responsibility of conducting IDD L2 assessments. 4
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 if they 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. 5
PASRR Began with Federal Nursing Home Reform Laws: OBRA 1987. Omnibus Reconciliation Act Federally mandated in every state. Addresses service and support needs of persons with disability in NFs. Focused on the needs of the whole person (primarily, but not solely disability needs). Focused on NF supports and care plans for persons with disability conditions and on the individual s quality of life, not just at admission but for entire NF stay. Puts requirements on all entities responsible for PASRR to thoroughly look at and describe each individual s unique needs. Puts requirements on NFs to assure PASRR identified services are delivered. Puts requirements on states to assure PASRR identified services are available. 6
Other than release of a complex transmittal in 1988, issuance of the 1992 final regulations and the 1997 repeal of Annual Resident Reviews, (removing the second A from PASARR) CMS provided no guidance or direction for the 20 years after OBRA 87 was released. 7
As with many programs, PASRR has several risk potentials, including: 1. Does the Level I ensure that everyone with a history or suspicion of a disability is identified? 2. Can we show evidence that our Summary of Findings reports lead to the most appropriate placement for persons with disabilities? 3. Can we show evidence that people with disabilities are receiving PASRR identified care, including SS? 4. Do we know how to maximize resources to get PASRR right? Each of these risks, must be evaluated to ensure federal PASRR compliance. 8
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. 9
According to CMS, to reach PASRR s goal, we must follow some fundamental steps. First, we must identify nursing facility applicants and residents with disability to ensure we are working with the population that most needs the PASRR services and supports. We must identify an appropriate placement to meet the individual s needs this could be a nursing facility, community placement, assisted living facility, psychiatric hospital, ICF/IID, or other setting to ensure service/support delivery in the least restrictive level of care; and, the individual should receive with whatever disability supports and services he or she needs. If a NF cannot arrange or provide a person s needed services, the NF would not be an appropriate location for the individual and alternate arrangements are necessary. It is important that we place individuals in a location that can meet their needs. This is among the reasons why it is so very important to read the PASRR determination before accepting a person for admission to your facility. 10
Currently, 560,000 individuals with mental illness reside in nursing facilities across the nation. Although interventions by mental health specialists can positively influence an individual s quality of life, 50% of nursing facilities surveyed in 2007 reported a serious lack of mental health resources available to them and their residents and an equal number specifically noted that mental health professionals were reluctant to provide services to their residents. The big picture is that PASRR is important because it ensures that people with disabilities get the services they need while in a nursing facility, and PASRR is important because it identifies and reports about the services and supports people will need in order to make the transition back into their communities. Section Q was added to the MDS to address this specific element of care and offers the individual an opportunity to voice his/her preference regarding choice and place of residence. 11
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 leads to increased loneliness and earlier mortality. Keeping a person centered focus can reduce the risk of suicide. This is because NFs: Were historically medically focused Were lay persons Experienced the most significant turnover of all health care providers Were and still are very busy 12
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 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. 13
PASRR is made of two primary components. Let s take a closer look 14
The preadmission screening and resident review process, otherwise known as PASRR, is a federally mandated process to ensure nursing facility applicants and residents with serious mental illness and/or intellectual and developmental disabilities are identified and placed appropriately in the least restrictive setting. PASRR ensures that persons with disability are admitted or allowed to remain in a particular nursing facility only if they can be appropriately served in the facility. PASRR ensures that individuals are provided with the disability services they need, including rehabilitative and specialized services. The goal of PASRR activity is to optimize each individual s placement success, treatment success, and ultimately, the individual s quality of life. PASRR components include a Level I screening. 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. 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 16
evaluation by an Ascend clinical professional. 16
After a Level II evaluation is conducted, a summary of findings report is generated. 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. 17
The first step is the Level I screening. This screen identifies if the person could potentially meet PASRR criteria. 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. 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 PASRRidentified 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.
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. 19
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, note any required documentation to obtain the categorical or exemption. 20
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! 21
Let s talk about LI screens. As we discussed earlier, Level I screens are the identification portion of PASRR. These help us identify if a person has a known or suspected diagnoses of MI, ID, or RC. You will notice questions about substance abuse, dementia, symptoms, timeframes, and medications. We find that to truly identify those with a suspected diagnosis, sometimes we have to dig just a little deeper. We know that people with a history of substance use have a higher likelihood of symptoms related to mental illness, even if they don t have a formal diagnosis. We also know that people with a lot of disruption in their lives evictions, multiple short term jobs or inconsistent work history, or few long term relationships can also have undiagnosed mental illness. The presence of any one of these things does not specifically equal a major mental illness, but the person has the right for us to look just a little closer at their circumstances to make sure they don t meet PASRR criteria. The more accurately we identify those in PASRR population, the better the NFs can meet their needs and ensure a better transition, better placement options, and a happier and more successful life. 22
As you can see, we average just under an hour for completing a Level I. If the person has any diagnoses, symptoms, or behaviors, we are likely going to ask for additional information. If providers submit a recent psych eval, H&P, or other supporting documents, we won t have to put the screen on hold while we wait to receive them. AND, if a person requires a Level II, we will need this information and more before we can move on. 23
Some of the concerns we hear from providers revolves around delays. Providers play a role in ensuring we can perform optimally. To assist, they can: 1. Fill out the level I completely. We have to research inconsistencies, questions, and missing information. 2. Return any required practitioner certifications. If they don t submit it with the screen but indicate the person meets the criteria, then we need to request it and can t issue a decision without it. 3. If the person received a psych eval in the hospital and they are in the hospital at the time of the level I screen, submit that psych eval with the screen. We will ask for it if not include. 24
The conversion rate is calculated by dividing the number of total Level I Screens (Web Approved and Clinician Reviewed) by the number of screens that resulted in an outcome of refer to level II. For example, in Jan 2016, we received 4022 total Level I submissions, and of those, 257 had an outcome of refer to Level II, resulting in a rate of 257/4022 or 6.39%. I thought the rate looked a bit low prior to mid 2015. Around April 2015, it appears the rate increased to around 5% and is now hovering around 6 7%. That s right where we want it to be. 25
Just as the first phase is called a Level I, the second phase is called a Level II. 26
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. 27
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. 28
States are increasingly viewing PASRR as a component of their overall community based system of supports, a tool for ensuring that individuals are receiving the services appropriate to meet their needs in the least restrictive, most integrated setting. When individuals must receive services in a NF due to their needs, states are using PASRR as a critical transition component. Specialized services can include services that build skills needed for successful community living. Provider resources may include Home and Community Based Services (HCBS) providers, which can build an extremely effective bridge between the NF and community and potentially excellent continuity of care at and after discharge. States are also beginning to utilize information available through MDS and other data sources to identify current residents of NFs who may be better served in the community. In thinking of PASRR as an integrated component of the service delivery system, states are exploring how to create bridges to more seamless transitions. 29
PASRR.com offers many resources that will help you become more informed about PASRR, complete assessments & screens with ease, and learn about changes in requirements and processes. This is our first line of communication with providers. On this page, you can find links to documents, manuals, videos, and presentations on a host of PASRR related information. We have contact information, upcoming webinars and trainings, and recordings of previous trainings. When you have a question, the answer is likely on this page. Visit it often to keep learning more about PASRR, Ascend, DHS, and what resources are available to you. We also use constant contact to communicate with providers directly. A few things to point out about constant contact please add Ascend, A MAXIMUS Company as a safe sender (your IT department or a tech savvy colleague should be able to help). Also, if you have ever unsubscribed to an email sent through constant contact, you might not receive announcements. If you or anyone you know is not receiving Iowa PASRR related announcements, but would like to be, please ask them to use the, click here to join the Iowa PASRR update email list, and begin receiving all announcements. 30
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