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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: [email protected]
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
2
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.
3
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
6
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.
7
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.”
8
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.
9
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.
10
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.
11
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.
12
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…
13
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.
14
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).
15
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
16
Level I Screening:
Forms
17
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
18
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
19
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’.
20
Level I Screening:
Structure and
Infrastructure
21
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
22
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.
23
Level I Screening:
The Conundrums
24
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
27
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
28
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
29
Level I Screening:
Quality Assurance
30
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.
32
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
33
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
34
Level I Screening:
When Introducing
Change…
35
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: [email protected]
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:
(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)
38
Final thoughts and questions