Transcript Connecticut PASRR and NF Screening

Connecticut
PASRR
and
NF
Connecticut
Screening
PASRR for Hospitals:
An introduction.
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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
© 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.
© 2009 Ascend Management Innovations, LLC
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
© 2009 Ascend Management Innovations, LLC
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PASRR answers 3.5 questions
• 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?
© 2009 Ascend Management Innovations, LLC
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.
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Question1: Does the individual meet criteria for a
PASRR diagnosis of serious mental illness?
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.
© 2009 Ascend Management Innovations, LLC
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The PASRR SMI category does not
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
© 2009 Ascend Management Innovations, LLC
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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 community
o In own home
o With available community or
Waiver services
© 2009 Ascend Management Innovations, LLC
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Question #3: Does the Individual Have
Special Service Needs?
© 2009 Ascend Management Innovations, LLC
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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”
© 2009 Ascend Management Innovations, LLC
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:
© 2009 Ascend Management Innovations, LLC
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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 period
Ascend 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
© 2009 Ascend Management Innovations, LLC
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Exemption 2: When an individual has
MI and dementia, where dementia is
primary and advanced
Required 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
© 2009 Ascend Management Innovations, LLC
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Level I/ II categorical decisions:
Option where
one of the
two PASRR
decisions can
be made by
virtue of the
person fitting
into a certain
category
Those categories
are….
© 2009 Ascend Management Innovations, LLC
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Categorical 1: Provisional Emergency
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
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
© 2009 Ascend Management Innovations, LLC
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Categorical 2: Provisional delirium
The 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
© 2009 Ascend Management Innovations, LLC
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Categorical 3: Respite (30 days)
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.
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
© 2009 Ascend Management Innovations, LLC
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Categorical 4: Terminal Illness
The 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.
The admitting facility must
•
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.
© 2009 Ascend Management Innovations, LLC
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Categorical 5: Severe Illness
Coma, 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
The referral source must:
The admitting facility 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.
© 2009 Ascend Management Innovations, LLC
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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
© 2009 Ascend Management Innovations, LLC
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Onsite Level II information will
generate…
…a summary PASRR report
that documents:
1. The individual’s history and needs
2. The state’s obligation for specialized services
3. The nursing facility’s obligation for
rehabilitative services
4. The nursing facility’s obligation for monitoring
the individual’s needs
* Required by Federal law
* Monitored by Survey and Certification
© 2009 Ascend Management Innovations, LLC
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Level II Outcomes
APPROVAL of placement in
NF
• Appropriate for NF ongoing
• Appropriate for short-term NF
placement
DENIAL of placement in the NF
 Does 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
© 2009 Ascend Management Innovations, LLC
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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
An Ascend nurse
may review some
PASRR Level I
screens with you
Most negative Level I
outcomes (approving
NF admission) will be
available immediately
to print out
Additional
information may
be requested to
clarify status
Some may be
referred for a
comprehensive
Level II Evaluation
Approval for NF
admission will
typically occur within
a few hours of
submission
© 2009 Ascend Management Innovations, LLC
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Electronic Level I and LOC Entry
© 2009 Ascend Management Innovations, LLC
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Mental Illness:
Known
or suspected
diagnosis
Mental Illness: Disability
Mental Illness: Duration
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Level I, P2
Dementia
Medication: drop
down list (List all
psychotropics. Evaluates
for potential dementia
and MI with heuristics
using the Beer’s List)
Mental
Retardation and
Related Conditions
Exemptions and
Categorical
Decisions
© 2009 Ascend Management Innovations, LLC
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Level I, P3
Categorical
Decisions
(Continued from
Previous Page)
Guardianship
Information (if a
Level II condition is
present)
Ascend
Recommendatio
ns (for Categorical
Decisions)
© 2009 Ascend Management Innovations, LLC
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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
Additional
information may be
requested to support
medical criteria
Approval decisions
within a few hours.
• short –term
• ongoing.
An onsite evaluation may
be needed to confirm
LOC criteria in some
cases.
© 2009 Ascend Management Innovations, LLC
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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.
© 2009 Ascend Management Innovations, LLC
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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., shortrange 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.
© 2009 Ascend Management Innovations, LLC
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When a ST Stay Decision is Issued
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
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CT LOC Criteria
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Criterion A: Continuous nursing services
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.
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Criterion B: Substantial daily assistance
Chronic condition(s) requiring
substantial assistance with
personal care on a daily basis.
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
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CT LOC Need Factors: Overview
1. 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 definitions
Rating
Independent
or Supervision
< daily
Definition
Individual independently accomplishes the activity in a way that
assures health and /or requires supervision less than daily.
The individual requires support such as monitoring, observing,
verbal or gestural prompting, verbal coaching and gestural or
Supervision or pictorial cueing in order to accomplish the task. The support is
cuing daily
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.
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ADL Item Definitions
Measured
ADL
Bathing
Dressing
Eating
ADL Definition
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.
Supports 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.
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.
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ADL Item Definitions, continued
Measured
ADL
ADL Definition
Toileting
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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Cognitive need factor definition
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
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Behavioral health indicators, definitions
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.
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LOC Form
Application type
Demographics
Activities of daily
living
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LOC Form
Page 2
Medication supports
needed
Cognitive orientation
and needs
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LOC Form
Page 3
Behavioral needs
Medications
prescribed, can attach
a copy of the MAR
Rehabilitation
services needed
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LOC Form
Page 4
Explanations and
descriptions
Physician attestation
Submitter attestation
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Introduction
to
WEBSTARS™
On-Line Submission of Screening & Tracking
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www.PASRR.com
• Forms
• Instructions
• Managing
Passwords
• Signing on
• Tutorial
©2009 Ascend Management Innovations LLC
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Permissions for access
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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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™
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.
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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.
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.
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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.
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
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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