PASRR LEVEL I DISABILITY SCREENING: PREPARING FOR THE 2014 REVIEW NANCY SHANLEY VP OF CONSULTING & POLICY ANALYSIS ASCEND MANAGEMENT INNOVATIONS EMAIL:

PASRR LEVEL I DISABILITY SCREENING: PREPARING FOR THE 2014 REVIEWNANCY SHANLEYVP OF CONSULTING & POLICY ANALYSISASCEND MANAGEMENT INNOVATIONSEMAIL: [email protected]

MARCH 2014 NAPP PASRR CONFERENCE

© 2014 Ascend Management Innovations LLC. All rights reserved. 1

mailto:[email protected]

© 2014 Ascend Management Innovations LLC. All rights reserved.

2

Agenda

Big PictureRequirementsFormsProgram Structure and InfrastructureConundrumsLeveraging Level I Screening DataQuality AssuranceInformation TechnologyIntroducing Change


PASRR—The Big Picture3

Goal of PASRR: 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. Do meaningful, powerful Level II evaluations

Goal of PASRR Level I Disability Screen: 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. Everyone who would benefit from a Level II

gets one


A Reminder: Why PASRR is Important

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Few disability-specific services are NF’s responsibility

PASRR is a key route to identify and deliver disability services to NF residents

Fail to identify= fail to deliver


LEVEL 1 SCREENING: THE REQUIREMENTS

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Level I Regulatory ReferenceSec. 483.128 PASARR evaluation criteria. (a) Level I: Identification of individuals with MI or MR. The State's PASARR

program must identify all individuals who are suspected of having MI or MR as defined in Sec. 483.102. This identification function is termed Level I. Level II is the function of evaluating and determining whether NF services and specialized services are needed. The State's performance of the Level I identification function must provide at least, in the case of first time identifications, for the issuance of written notice to the individual or resident and his or her legal representative that the individual or resident is suspected of having MI or MR and is being referred to the State mental health or mental retardation authority for Level II screening.

(c) Group determinations by category. Advance group determinations by category developed by the State mental health or mental retardation authorities may be made applicable to individuals by the NF or other evaluator following Level I review only if existing data on the individual appear to be current and accurate and are sufficient to allow the evaluator readily to determine that the individual fits into the category established by the State authorities (see Sec. 483.132(c)).


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Level I Regulatory Requirements—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 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), or

Document that the possible presence of a PASRR condition cannot be ruled out (a Level II evaluation is required), and

Document when information is sufficient to apply certain predetermined PASRR criteria (hospital exemption and/or categorical determinations).


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Level I Screen: Musts

Capture all persons with suspected or known SMI, ID, or RC/DD

Look beyond reported diagnoses, known interventions

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

kinds of 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


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Level I Screen: Value-added

Be specific Include relatively few people

who do not need a Level II evaluation

Helps use Level II resources effectively


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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.

PTAC study


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.”


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 EvaluationsStates 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.


LEVEL I SCREENING: THE CONUNDRUMS

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Match Level I Content and Process


High Effectivenes

sLow Cost

1Low Level I Screener

Credentials/High Level Detail

Centralized Interpreter

High Effectivenes

sHigh Cost

2High Level I

Screener Credentials/High

Level I DetailLow

Effectiveness

Low Cost

3Low Level I Screener

Credentials/Low Level I Detail

Moderate Effectivenes

sHigh Cost

4High Level I

Screener Credentials/Low

Level I Detail

Ef

$

L1

Scr

Ef

$ L1

Scr

Ef

$

L1

Scr

Ef

$ L1

Scr

EF

FE

CT

IV

EN

ES

S

C O S TLOW COST

HIGH COST

LOW EFFECTIVENESS

HIGH EFFECTIVENESS


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Conundrums

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


LEVEL I SCREENING: QUALITY ASSURANCE


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Who is Responsible for Ensuring the Quality of Level I Disability Program?

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.


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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.

INFORMATION TECHNOLOGY



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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


Web-Based Level I Submission Systems

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© 2014 Ascend Management Innovations LLC. All rights reserved.31


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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


LEVEL I SCREENING: WHEN INTRODUCING

CHANGE…


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What to Expect When Moving From…

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


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Final Thoughts & Questions

Nancy ShanleyVP of Consulting and Policy AnalysisAscend Management InnovationsEmail: [email protected]: 615.473.4554WWW.ASCENDAMI.COM

mailto:[email protected]

http://www.ascendami.com/


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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 Exemptions and categorical

determinations are often part of the Level I processes

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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Level I Regulatory Requirements Provide written notice

Procedures for screening process, tools, and training for screeners

Referrals for Level IIs for residents (status changes): procedures training regarding

identification of a PASRR condition

Documents

PASRR LEVEL I DISABILITY SCREENING: PREPARING FOR THE 2014 REVIEW NANCY SHANLEY VP OF CONSULTING & POLICY ANALYSIS ASCEND MANAGEMENT INNOVATIONS EMAIL: