Connecticut PASRR and NF Screening Connecticut PASRR for Hospitals: An introduction.

Connecticut PASRR and NF Screening

Connecticut PASRR for Hospitals:

An introduction.

What has changed?•New form required for PASRR Level I (MI/MR)•New form required for Level of Care (Health

Screen)•Both forms submitted via the web to Ascend •No longer submitted to DSS Acute Care Unit

▫Ascend nurses versus ACU nurses will review forms

•NF reimbursement contingent on PASRR and LOC approval prior to NF admission

•Short term NF stay approvals more common• If the Level I (MI/MR) is positive:

▫Ascend’s in-state clinicians will conduct onsite Level II evaluations

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© 2009 Ascend Management Innovations, LLC

What has not changed?• A Level Of Care (Health Screen) must be

completed for the very same group of people that have a LOC screen now (65 years of age or older and Medicaid active, eligible or pending and persons going through a Level II evaluation)

• A Level I (MI/MR) is done for all persons seeking admission to a Medicaid certified NF

• Hospitals will be paid for the LOC screen and for the extra documentation required when an exemption or categorical is requested and approved.


Required PASRR Components:Required PASRR Components:Level I (broad screening)

Is there any suspicion of Serious MI, MR, DD/RC?

Level II (comprehensive evaluation) Individualized & comprehensive evaluation to confirm

suspected diagnosis Make placement and treatment recommendations Is NF the most appropriate placement (including LOC

appropriate)?

Report and notifications Legal document with placement and treatment

ramifications Must be timely and serve to interpret and explain the

PASRR process and outcome. After notification, the individual or family may appeal any

decision made

Follow-up assessments Called Resident Reviews or Change in Status evaluations PASRR laws insure that individuals admitted to the NF

continue to be monitored for placement and treatment appropriateness


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•Question 1: Does the individual meet this state’s criteria for a PASRR target diagnosis (SMI, MR, or RC)?

•Question 2: What is the most appropriate placement for this individual now?

•Question 2.5: Might this individual at some point be a candidate for transition to community services?

•Question 3: What types of services are needed for the individual to be successful in the recommended placement? What kinds of supports would be necessary to return to his/her community?

PASRRPASRR answers 3.5 answers 3.5 questions questions


Connecticut's process for conducting Level II evaluations for individuals with indications of possible mental retardation or possible related conditions (developmental disability) will remain the same.

Ascend will refer positive Level Is with indicators for these conditions to the Department of Developmental Disabilities Services.

The DDDS will continue to conduct these Level II PASRR evaluations.

Question1: Does the individual meet criteria for a PASRR diagnosis of serious mental illness?

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Criteria: The 4 ‘D’s

Diagnosis or credible suspicion of a major mental illness. • For example: schizophrenia, schizoaffective disorder, bipolar disorder,

major depression, panic disorders, obsessive compulsive disorder• Does not have primary or sole diagnosis of dementia.

Duration: Due to the disorder, significant disruption or major treatment episodes within the past 2 years.

Disability: Level of impairment characterized by active symptoms within the preceding 6 months related to interpersonal functioning, concentration/pace/ persistence, or adaptation to change. Or current episode with the potential for serious disruption.


The PASRR SMI category does The PASRR SMI category does notnot include…. include….

•People with situational emotional conditions

•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


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Question #2: What is the most appropriate placement for this individual?

• In a nursing facility • In an assisted living facility• In a psychiatric hospital• In another type of facility• In a placement in the

communityo In own homeo With available

community or Waiver services


Question #3: Does the Individual Have Special Service Needs?

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There are two kinds of special service needs every PASRR Level II must discuss:

1. Rehabilitative needs – those that the NF is responsible to meet. These include any range of services, along with clear/layman recommendations to promote the success of the individual’s placement.

2. Specialized Service needs – those that require specialized MH professionals to deliver, such that the NF is not responsible to provide. The state is responsible for addressing these needs.

States have leeway to define and interpret the definition of “specialized services”

Whenever a Level II evaluation is triggered, PASRR activities must be complete before NF admission can occur

•There are a few federally allowed options for admission to NF prior to a full face-to-face Level II evaluation and write-up

Let’s review those 7 options and when they can be used:


Exemptions:1. Exempted hospital discharge criteria:

▫Admission to a NF from a hospital after receiving 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 referral source has completed a LOC form confirming the individual’s medical need for NF services

The MD’s certification can be faxed or uploaded as a pdf and attached to the electronic Level I

©2009 Ascend Management Innovations LLC

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Exempted hospital discharge requirements

The discharging provider•Completes the Level I

•Uploads or faxes a signed copy of the MD statement, or a signed MD note from the record affirming < 30 NF day stay anticipated

•Completes the Level of Care form

The admitting facility•Confirms accuracy of the Level I/ LOC screens•Contacts Ascend by or before 30 days when NF is needed beyond the authorized periodAscend will initiate a Level II evaluation which must, under federal law, be completed by or before the 40th calendar day from the individual’s admission to the NF

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Exemption 2: When an individual has MI and dementia, where dementia is primary and advancedRequired action: • Level I referral source must provide information

to Ascend which clearly supports that the dementia is advanced and will always remain primary over the mental health diagnosis

• Supporting documents may be faxed or uploaded as a pdf and attached to the electronic Level I

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Option where one of the two PASRR decisions can be made by virtue of the person fitting into a certain category

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Those Those categoriescategories are….are….

Level I/ II categorical Level I/ II categorical decisions:decisions:


Categorical 1: Provisional Emergency The admitting facility must:

• Submit a Level I and LOC form within one business day of the individual’s admission

• And identify name and contact information of PSE initiator.

• Affirm there is no current risk to self or others and behaviors/ symptoms are stable

• If the individual does not meet NF LOC, Ascend will notify the NF and PSE worker

• If positive Level I, a Level II must occur by the 7th day

• Discharge must be initiated if NF not appropriate

Provisional Emergency Criteria: •Emergency protective services situation NF care needed for no greater than 7 calendar days. •The admission must be initiated by Protective Service for the Elderly (PSE) staff•DSS has noted that this Categorical option cannot be utilized for persons currently in the hospital or ED

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Categorical 2: Provisional deliriumThe referral source must: • Provide documentation to the

Ascend reviewer that supports the delirium state

• Complete a Level of Care Screen.

If the individual’s admission is approved by the Ascend reviewer, the admitting facility may admit the individual for a period of 7 calendar days.

The admitting facility must

• By or before the 7th day, the Ascend clinician will review the initial Level I/ LOC screening information with the NF staff to ensure its continued accuracy

• And to determine if a Level II is warranted

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Categorical 3: Respite (30 days) The admitting source

must:• By or before the 30th

day, the Ascend clinician will review the initial Level I/ LOC screening information with the NF staff to ensure its continued accuracy

• And to determine whether a Level II is warranted

The referral source must • Level of Care (LOC) form

which must be approved by Ascend before the admission can occur

• Submit a Level I with documentation that describes and supports the individual’s need for respite care

• Affirm there is no current risk to self or others and behaviors/ symptoms are stable

If approved by the Ascend reviewer, the admitting facility may admit the individual for a period of 30 calendar days.

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Categorical 4: Terminal IllnessThe referral source must: •Submit Level I with documentation which supports the terminal status of the individual’s condition•In addition, information must be provided to confirm the stability of mental illness •Submit a completed Level of Care screen.

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• Submit an updated Level I and Level of Care screen to Ascend only if the severe medical condition improves to the extent that the individual might respond to services for his/her MI and/or MR/RC diagnosis.


Categorical 5: Severe IllnessComa, ventilator dependent, brain-stem functioning,

progressed ALS progressed Huntington’s etc.so severe that the individual would be unable to participate

in a program of specialized care associated with his/her MI and/or MR/RC

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The referral source must:

Submit Level I with documentation that describes and supports the individual’s severe medical state and to confirm the stability of the concomitant mental illness.

Complete a Level of care Screen.


• Submit an updated Level I and Level of Care screen to Ascend only if the severe medical condition improves to the extent that the individual might respond to services for his/her MI and/or MR/RC.


Federal requirement for comprehensive Level II

before NF entry

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Level II Evaluation

1. Onsite review of medical records, interviews with key respondents, collection of key clinical data points

2. Evaluation is sent to Ascend for quality review

3. Final determination summary is sent to the individual/ guardian, referral & receiving facility, PCP

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Onsite Level II information will generate…

1. The individual’s history and needs2. The state’s obligation for specialized

services3. The nursing facility’s obligation for

rehabilitative services4. The nursing facility’s obligation for

monitoring the individual’s needs

* Required by Federal law* Monitored by Survey and Certification

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…a summary PASRR report that documents:


Level II Level II OutcomesOutcomesAPPROVAL of placement

in NF• Appropriate for NF ongoing• Appropriate for short-term

NF placement

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DENIAL of placement in the NFDoes not meet minimum LOC standards Requires specialized services.

Therefore, needs inpatient hospitalization. Nursing facility placement denied.

HALTED from the PASRR process

All denial notices (adverse decisions) include appeal rights


Nuts and Bolts of the PASRR Level I screen

(MI/MR)

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Connecticut PASRR Level I Screens

Discharge planner submits PASRR

Level I

Most negative Level I outcomes (approving NF

admission) will be available

immediately to print out

An Ascend nurse may

review some PASRR Level I screens with

you

Some may be referred for a

comprehensive Level II

Evaluation

Approval for NF admission will typically occur

within a few hours of submission

Additional information

may be requested to clarify status

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Electronic Level I and LOC Entry

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Mental Illness: Duration


Mental Illness: Disability

Mental Illness: Known or suspected diagnosis

Level I, P2

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Medication: drop down list (List all psychotropics. Evaluates for potential dementia and MI with heuristics using the Beer’s List)

Mental Retardation and Related ConditionsExemptions and Categorical Decisions

Dementia


Level I, P3

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Guardianship Information (if a Level II condition is present)

Ascend Recommendations (for Categorical Decisions)

Categorical Decisions (Continued from Previous Page)


Nuts and Bolts of the PASRR Level of Care screen

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Connecticut Level of Care Decisions

Discharge planner submits Level of

Care

Approval decisions within a few hours. • short –term • ongoing.

Additional information may be requested to support medical

criteria

An onsite evaluation may be needed to

confirm LOC criteria in some cases.

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Who must have an Ascend LOC screen?

•The same individuals who require a screen under the current system

•Individuals 65 and older who are Medicaid active, eligible, or pending who are seeking NF admission

•All individuals seeking NF admission who have a positive Level I and are determined by the Level II evaluation to have a PASRR target condition.

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LOC Outcomes• Long-term approval: Needs qualify for NF long-

term. No set review date established.

• Short-term approval: Needs qualify for NF LOC on a short-range basis of three (3) to six (6) months and no greater than a six (6) month timeframe (e.g., short-range restorative potential).

A Continued Stay Review (CSR) date will be set. Ascend will track the individual. The individual needs to be re-reviewed by the end

date.

• Denial: If the individual’s needs do not meet NF LOC, Medicaid will not pay for nursing facility care. All denial decisions shall be issued by one of Ascend’s physician reviewers.

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When a ST Stay Decision is Issued

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The referral source must:

Print ST approval Give to admitting NF as proof of approval

The admitting facility must:

Inform Ascend of admission (on-line with Tracking Change Request Form)At end of approved stay, submit an updated LOC screen to Ascend

Ascend will:

Issue a letter to the receiving NF with an authorization end date

One week prior to the end date, Ascend coordinates CSR with NF© 2009 Ascend Management Innovations, LLC

CT LOC Criteria

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Criterion A: Continuous nursing services

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Presence of uncontrolled and/or unstable and/or chronic condition

requiring continuous skilled nursing services

as evidenced by diagnosis(es), therapies, services, observation requirements, and/or frequency.

Criterion B: Substantial daily assistance

Chronic condition(s) requiring substantial assistance with personal care on a daily basis.

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Criterion B, Continued: CT criteria for substantial daily assistance

Substantial daily personal care is evidenced by one or more of the following:1. Chronic condition + supervision ≥ 3 ADLs daily + need

factor 2. Chronic condition + hands-on ≥ 3 ADLs 3. Chronic condition + hands-on ≥ 2 ADLs daily + need

factor

4. Dementia which, supported with corroborative evidence, has resulted in cognitive deterioration to the extent that a structured, professionally staffed environment is needed for daily monitoring, evaluating and/or accommodating to the individual’s changing needs

CT LOC Need Factors: Overview1. Rehabilitative Services 5X Week PT, OT, ST,

RT. The individual has restorative potential. Delivered at least five times a week

2. Cognitive Need: Requires presence of a caregiver daily for supervision to prevent harm due to a cognitive impairment

3. Behavioral Need: Requires the presence of another person at least daily for supervision to prevent harm

4. Medication supports: Requires the assistance for administration of physician ordered daily medications. Includes supports beyond set ups

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ADL rating definitions42

Rating Definition

Independent or Supervision < daily

Individual independently accomplishes the activity in a way that assures health and /or requires supervision less than daily.

Supervision or cuing daily

The individual requires support such as monitoring, observing, verbal or gestural prompting, verbal coaching and gestural or pictorial cueing in order to accomplish the task. The support is needed daily. No hands-on support is needed.

Hands-on support

Physical assistance from another person is needed to initiate or complete the task or activity in a way that assures health and safety. Even with diligent verbal or gestural cues the individual requires physical assistance or intervention to accomplish the task.

Total dependence

The individual is incapable of performing substantial parts of the task without assistance of another person or persons.

ADL Item Definitions

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Measured ADL

ADL Definition

Bathing Supports needed to cleanse all parts of one’s body and hair, by showering, tub or sponge bath to maintain proper hygiene and prevent body odor. Includes supports needed get into and out of the tub or shower or make preparations needed for a sponge bath. Includes support to use a transfer bench if needed to get into and out of a tub or shower. Excludes: getting to and from the bath or shower room, which is addressed in mobility or routine hygiene throughout the day, which is included in grooming.

DressingSupports needed to select appropriate clothing; to put on, take off and adjust clothing items, including buttoning and fastening.. Excludes: Intensive restorative or therapeutic interventions (applying salves or ointments for the treatment of infection) for teeth or nails, as those are medication administration considerations.

Eating Supports needed to use utensils or adaptive devices to get food from plate to mouth. Includes supports needed for activities related to ingestion by nasogastric gastrostomy, jejunostomy or parenteral route. Excludes: Supports needed for meal preparation or for supervision of obesity or weight reduction.

ADL Item Definitions, continuedToileting Supports needed to or appropriately use toileting equipment; to

doff, don and adjust clothing; and to attend to hygiene after toileting. Includes supports needed to transfer to/from the toilet and supports needed to manage ostomy equipment or use a catheter.

Continence Includes supports needed to either: assist the individual to control one’s body to empty the bladder and/or bowel appropriately, or, to appropriately change incontinence pads/briefs, cleanse the changing pads, and dispose of soiled articles.

Transferring Supports needed to move from surface to surface or position to position safely (e.g., into and out of chair or wheelchair, from bed or chair to standing and back) with or without the use of assistive devices/ adaptive modifications. Excludes: getting into and out of bath or shower, which is addressed in bathing –and- getting onto and off toilet, which is addressed in toileting.

Mobility Supports needed to move safely about the environment, from and to locations that are a part of the individual’s daily life, with or without assistive devices/adaptive modifications.

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Measured ADL

ADL Definition

Cognitive need factor definition

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Cognitive Impairment Indicator Requires presence of a caregiver daily for supervision to prevent harm due to a cognitive impairment, with severe cognitive deficits evidenced by impairments in one or more the following areas:• Memory: Unable to remember past and present events such

that 24 hour supervision is needed to prevent harm• Orientation: Disoriented to person, place, and time such that

the individual demonstrates a significant lack of health and safety awareness

• Judgment: Unable to solve problems well and make appropriate decisions

• Communication: Inability to communicate information in an intelligible manner and/or understand information conveyed

Behavioral health indicators, definitions

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Behavioral Health Indicator Requires the presence of another person at least daily for supervision to prevent harm due to one or more of the following: Abusive/Assaultive behavior: Abusive refers to physically causing harm to self or other; verbal assaults such as threatening physical attack or menacing in other ways. Assaultive refers to the individual’s attempts at or accomplished physical violence upon another person Unsafe or Unhealthy Hygiene/ Habits: Unacceptable hygiene or eating habits such as throwing or smearing food or excrement, disrobing in inappropriate situations, screaming, making inappropriate sexual advances. Wandering: Aimless movement and/or roaming or straying from proper limits. Threats to Health/Safety: Inability to follow a medication or dietary regimen without supervision; creating a fire hazard; exhibiting poor judgment which is potentially harmful to self or others.

LOC Form

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Demographics

Application type

Activities of daily living

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LOC FormPage 2

Medication supports needed

Cognitive orientation and needs

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LOC FormPage 3

Behavioral needs

Medications prescribed, can attach a copy of the MAR

Rehabilitation services needed

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LOC FormPage 4

Explanations and descriptions

Physician attestation

Submitter attestation

Introduction to WEBSTARS™

On-Line Submission of Screening & Tracking

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www.PASRR.com

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•Forms•Instructions

•Managing Passwords

•Signing on•Tutorial

1.ONLY supervisors can set up access for individual agency users.

2.Supervisors can only give access to persons they supervise.

3.Supervisors will be required to confirm/ update users access privileges frequently.

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Permissions for access

Supervisor Registration www.pasrr.com

• Step 1: Log onto www.pasrr.com, locate the link on the right labeled “Connecticut WEBSTARS™ and click the link to enter

• Step 2: Click on the “Supervisor Registration” icon on the Connecticut WEBSTARS™ home page. Complete the registration form and click submit.

• Step 3: Ascend will forward an email within 2 business days to the supervisor which will reflect whether the supervisor has been approved.

• Step 4: Once you have received the email approval, go to supervisor login & set up facility users.

• Each identified user will receive an email within 2 business days with a link to access WEBSTARS™.

• Once agency staff receive emails from Ascend approving system access, they may begin using WEBSTARS™.

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User Registration• Step 1: The agency supervisor requests user privileges

through WEBSTARS™ for each individual staff. Ascend does not issue user names and passwords.

• Step 2: Ascend will forward an email within two business days which will include authorization for that employee and a link to WEBSTARS™. The new user may access the link provided in the email and reset his/her password. The employee should click on the link and create their own individual password.

• Step 3: Log onto www.pasrr.com. Locate the link labeled “Connecticut WEBSTARS™” and click to get started.

• Step 4: Follow instructions for submitting screening forms.

If you do not have internet, or you are unable to submit Level I screens online, fax the Level I PASRR form to Ascend at 877-431-9568.

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Signing onto WEBSTARS™

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Enter your unique name and password and note user agreement specifications

associated with attestation of information accuracy.

Choose ‘No’. Passwords should never be saved on the computer.

Other WEBSTARS™ Instructions

• Form omissions and saving capabilities. WEBSTARS™ will not permit incomplete submissions. Incomplete items will turn pink. You may save the form for 48 hours.

• Form submission. Once all items are complete, press the submit button at the bottom of the form. All LOC reviews will require further involvement by an Ascend clinician. Some Level I screens will require review.

• Form Printing. The submitter will be directed to a page that will enable him/her to print the results of the LOC or Level I screen. Use this page to direct any printing. Never use the browser print functionality to print your screen.

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Update on accessing Level I reviews in progress

•Webstars™ will allow web-supervisors to access all Level I and LOC submissions made by their assigned web-supervisees.

•Webstars™ will allow web-supervisors to enter and submit updated information, to monitor the status of submissions, and to print outcome notices for all submissions made by their assigned web-supervisees.

Disposition and Outcomes• Disposition information: Information needed by

the Ascend reviewer will be posted. Decision outcomes will be posted. The submitter may sign on to verify outcome or communicate with Ascend.

• Outcomes: Print the completed screen for the client’s record & to provide to the admitting facility. ▫ Approvals. If approval was provided through

WEBSTARS™, the patient may be admitted to the Medicaid certified nursing home.

▫ Level II referral. Once complete, the Level II notice and report will be posted on WEBSTARS™

▫ Deferrals for Physician Review. If further Ascend review is needed by an Ascend physician for a potential denial, the WEBSTARS™ disposition screen will indicate the estimated time the Ascend reviewer will call with questions or approval.

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Quality Monitoring

DSS requires that Ascend randomly flag and conduct post-admission quality monitoring activities for:

•Individuals with a heightened potential for significant status change. This activity evaluates NF compliance with mandatory status change reporting.

•A percentage of individuals with negative Level I screens. This activity evaluates referral source compliance and Level I data integrity.

Results of these activities will be routinely reported to the Connecticut DSS.

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Training Resources for Provider staff: • Information on how to access video

presentation introducing providers to CT PASRR and LOC submission will be posted at http://www.pasrr.com/. Click Connecticut Webstars™ and then click Educational tools.

•Also found at this location ▫PowerPoint handouts for provider video

trainings. ▫The most up to date version of the Provider

Manual for CT PASRR▫The state’s answers to PASRR Frequently

Asked Questions

CT commitment to diversion

and transition

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DSS: CT Home Care Program for Elders

Home Care Request Form•Required in the same situations it is

currently required. •However, applications for the Connecticut

Home Care Program for Elders may be completed on-line at www.pasrr.com.

•You may immediately print Home Cares contact information to give to individuals.

• Ascend provides all information associated with the Home Care application to the Connecticut Department of Social Services.

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DMHAS role in CT PASRR

•Six Nurse Clinicians attached to local mental health authorities & DMHAS-funded agencies

•Available to help hospitals explore arrangements for ED individuals with suspected SMI awaiting Level II

•Will collaborate to assist persons denied NF LOC who need community services

•Will follow-up on short-term approvals for persons with SMI to assist NF with discharge planning

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Connecticut PASRR and NF Screening Connecticut PASRR for Hospitals: An introduction.

Documents

Transcript of Connecticut PASRR and NF Screening Connecticut PASRR for Hospitals: An introduction.