PASRR LEVEL I

DISABILITY SCREENING

PASRR TECHNICAL ASSISTANCE CENTER’S

POWER OF PASRR WEBINAR SERIES

NANCY SHANLEY

VP OF CONSULTING AND POLICY ANALYSIS

ASCEND MANAGEMENT

EMAIL: NSHANLEY@ASCENDAMI.COM

February 2013

Agenda

The Big Picture

The Requirements

The Conundrums

The Forms

Program Structure and Infrastructure

Leveraging Level I Screening Data

Information Technology

Quality Assurance

Final Thoughts

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PASRR—The Big Picture

CMS is more engaged than ever in promoting PASRR as a mechanism to improve quality of life for nursing facility residents with disability.

PTAC exists to assist states with everything from high level analysis to working together on nuts and bolts parts of PASRR programs.

A trend is building for measurement of PASRR quality, outcomes, and effectiveness. “Show us the data.”

The goal of PASRR is to ensure all persons with disability are identified, their needs measured, the full array of needed services and supports are detailed in written recommendations, and that recommended services and supports are delivered.

The goal of PASRR Level I disability screening is to ensure that the power of PASRR evaluations and recommendations are brought to bear for all persons in NFs who have a PASRR disability condition.

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A Reminder: Why PASRR is Important 4

More than ½ of people with disabilities are still residing

in institutions

560,000 individuals with mental illness in NFs

Numbers exceed all other healthcare institutions combined

Mental illness is often a key factor in need for NF placement

NFs serve the same number of persons with IDD as do

large developmental centers

Relatively few disability specific or disability tailored

services in NFs

Level I – Identifies:

Diagnosis or credible suspicion

Intellectual disability

Related conditions

Serious mental illness

Primary Dementia

Level I Screening:

The Requirements

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Level I Disability Screen: Purpose

To identify all persons who must have the Level II

Preadmission Screening (PAS) or Resident

Review (RR);

That is, to identify all applicants to and residents

of Medicaid-certified nursing facilities (NFs) who

possibly have serious mental illness, intellectual

disability or a related condition.

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Level I Regulatory Requirements,

the State Medicaid Agency:

Has the overall responsibility for the quality of all aspects of the state PASRR program (see 431.621 & 431.104)

Must assure that every new admission to a Medicaid certified NF receive a Level I screen before admission.

This includes both persons with and without Medicaid as payer source.

This includes mandating that “the state’s PASRR program must identify all persons who are suspected of having MI or [ID] as defined in sec. 483.102. This identification function is termed Level I.”

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Level I Regulatory Requirements

The PASRR MI and/or the IDD authorities (or

designated entity) must be notified whenever an

individual is suspected of having a PASRR condition.

Must document notification of the appropriate

authority.

Must have a system for tracking persons with a

suspected PASRR condition who are approved

through the hospital exemption.

The system must cue a full Level II when an

individual’s stay nears the 30th day.

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Level I Regulatory Requirements

For first time identifications, the individual and legal

representative must be provided written notice that a

PASRR condition is suspected or known and of the

referral to the PASRR MH or ID authority for a Level II .

Referrals for Level IIs for residents (status changes):

Must have procedures and training for NF staff regarding

ID of persons not identified on admission as having a PASRR

condition

Must have written procedures designating responsibility

for performing Level I screens, specified instruments,

and training for screeners.

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Level I Regulatory Requirements

As most states conduct exemptions and categorical

determinations as part of the Level I programs, it is

important to assure that your program for

approving exemption and categorical requests is

compliant.

Guidance for these activities was the subject of a

past PTAC webinar. The video of that presentation

can be accessed at the PTAC website.

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Federal Register References

The Level I evaluator should not just rely on “known

diagnosis” but should “use discretion in reviewing

client labels and look beyond diagnostic labels…

We do expect states to take reasonable measures to

assure that diagnoses are accurate…

We reiterate that because mental illness/ [intellectual

disability] diagnoses may be withheld from individuals

or their families.. We do not believe it is appropriate

to accept existing diagnostic information without

question.

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Federal Register References

It is clear to us that reliance on known diagnosis

would cause the process to miss individuals

whose mental illness or [intellectual disability]

had not been specifically identified…

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50 States, 50 Solutions

States are free to specify the methods

used to identify possible MI/IDD, as long

as the outcomes can be shown to be

accurate.

States determine personnel qualifications

for conducting Level I disability

identification screens.

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Level I Disability Screen Tasks:

Document that evidence is sufficient to rule out

all suspicion of PASRR conditions (more than lack

of a diagnosis in the record),

Document that the possible presence of a PASRR

condition cannot be ruled out (a Level II

evaluation is required),

Document when information is sufficient to apply

certain predetermined PASRR criteria (hospital

exemption and/or categorical determinations).

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Level I Screen Goals

Capture all persons with suspected or known SMI, ID, or RC/DD (looking beyond reported diagnoses)

Be sensitive (identify everybody it was meant to identify) No matter who the informants are and given the information

available at the time of the screening

No matter who conducts the screen or where it is done

No matter the person’s diagnoses, history, current presentation

Be specific (include few people who did not need to be targeted) Helps with effective use of Level II resources

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Level I Screening:

Forms

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How Level I Disability Screens vary

Who fills out the screen

When it is filled out

What information is gathered for or within the Level I screen

The length and depth of Level I screen items

Assumptions made about the knowledge base of the persons filling out the Level I screens

Whether or not Level I screens are reviewed by clinicians knowledgeable about disability

Whether heuristics/algorithms are built into the Level I screen

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Keys to Successful Level I Forms:

Match the form content to the level of expertise of

the screener

Short forms generally require more disability

knowledge and judgment

If you only ask “is there a diagnosis or a suspicion of a

diagnosis” you must ensure that your screeners can

discern “a suspicion of a diagnosis”

Forms suited for a screener who is a disability

layperson typically also ask about signs and

symptoms that can be observed or queried

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Keys to Successful Level I Forms:

Frame questions to identify previously

unreported disabilities;

‘Look beyond’ reported diagnoses to consider

potential evidence of undiagnosed PASRR

conditions;

‘Look beyond’ reported dementia diagnoses to

confirm presence of dementia;

When both dementia and mental illness are

present, gather sufficient information to

determine which condition is primary according

to the PASRR definition of ‘primary’.

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Level I Screening:

Structure and

Infrastructure

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Structure/Infrastructure Considerations

Is Level I disability screening a part of a larger

screening, referral, diversion, or eligibility process?

Paper systems versus paperless system

Who is eligible or required to complete the Level I

screen?

Integration of Level I with LOC

Integration of Level I outcomes with payment systems

Integration of Level I screening information with Level

II evaluation information

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Triggering Level II evaluations

States must choose a strategy to determine whether

individuals screened receive a comprehensive Level II

evaluation. Common strategies:

Conduct a Level II evaluation on anyone with a symptom,

diagnosis, or behavior that may indicate the presence of

a PASRR condition.

Have qualified and PASRR trained disability experts

either complete or review Level I screening information to

determine whether there is a potential disability condition

requiring a Level II evaluation.

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Level I Screening:

The Conundrums

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Match Level I content and process 25

Effectiveness

by cost

Conundrums 26

Records sometimes silent regarding disability

Diagnostic proof versus credible suspicion

Screener discomfort querying individuals regarding disability (stigma)

Subtleties in diagnostic presentation, distinguishing situational reactions from more serious mental health conditions, what to do with anxiety or adjustment disorders

High screener turnover, creates a need for “on demand” training

Related conditions often overlooked. Recognize the wide range of diagnoses that might constitute a RC.

Level I Screening:

Leveraging Level I

Data

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Use of Level I Screening Data

Level I quality oversight

Needs and gaps analysis

IMD monitoring

When the Level I and the NF LOC information

submission are part of the same data system,

powerful information exists describing persons

across the state with disability who seek NF stay

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Use of Level I Screening Data

# of Level I screens compared to # of NF admissions

# of Medicaid versus non-Medicaid Level I screens

% of Level I screens that lead to Level II evals

% of Level II evals finding the individual does not

have a PASRR condition

% of Level I screens utilizing each categorical option

and EHD

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Level I Screening:

Quality Assurance

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Who is Responsible for Assuring the

Quality of the Level I Disability Program? 31

The state Medicaid agency (SMA) has the overall responsibility

for the state PASRR program. A PASRR program is a required

element in the Medicaid state plan (42 CFR 483.104).

As such, SMA responsibilities include auditing and enforcement

functions, and funding PASRR activities.

The Medicaid authority may delegate responsibility for

conducting, contracting, or monitoring the Level I disability

screening process, but retains the responsibility to assure that

delegated entities do it and do it well.

Quality Monitor Level I Performance

Level I submitter fidelity (measures whether each

Level I screener consistently reports accurate and

thorough data about persons’ disability status)

Level I outcome fidelity (measures the likelihood that

persons with disability are not picked up by the

Level I)

E.g., a portion of negative Level I screens are followed

up to assure that individuals determined to have no

Level II condition truly have no Level II condition.

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Web-based Level I Submission Systems

Allow the state to control access to Level I submission; only authorized persons can submit (can require training, etc.)

Immediate access to printing Level I outcome documentation for the referring entity, accepting entity, and to print the notice to individual

Easily linked electronically to NF payment authorization systems to assure pre-admission Level I

Quality monitoring data easy to capture and readily available

Outcome of Level I screen can be linked directly to payment system

Provider by provider use of Level I can be compared

Research data re: NF population easy to gather with the Level I

Easily integrated with NF LOC information submission

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Information Technology

Algorithms and heuristics can be built to trigger

clinical review of questionable Level I screens

Faster Level I decisions

Gives 24 hour a day access for submission of Level I

screens

Electronic submission of supporting materials

Security and compliance

User experience easily tailored

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Level I Screening:

When Introducing

Change…

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What to Expect When Moving From… 36

Post-admission to pre-admission

Factor into the transition the impact on providers

Take time to educate and onboard providers

Anticipate increased Level I volumes

Performance tied to policy to performance tied to

payment

Educate and onboard providers

Possible increased Level I volumes

Assumed quality to measured quality

Gaps in the program WILL be identified

PASRR:

REAL STORIES,

REAL PEOPLE

Thinking about quality of life for persons with

disability

Nancy Shanley VP of Consulting and Policy Analysis

Ascend Management

Email: nshanley@ascendami.com

Phone: 615-473-4554

The slides and video for this presentation will be posted at:

www.PASRRassist.org

To submit an idea for a future PASRR tutorial webinar, email:

NAPPfrontdesk@PASRR.org

(States can obtain PASRR Technical Assistance from PTAC through the website www.PASRRassist.org or by

calling Ed Kako 415-263-9887 or Mason Smith 415.796.0166)

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Final thoughts and questions