Transcript Colorado Pre-Admission Screening and Resident Review

Colorado
Pre-Admission
Screening and
Resident Review
Level I
PAS and RR
Training June 2014
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Colorado Department of Health Care Policy and Financing
Colorado PASRR Level I and Resident
Review Simplification
Multiple forms
Multiple Interpretations
Multiple places to document
Multiple and confusing dates
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Colorado Department of Health Care Policy and Financing
Colorado PASRR Simplification
 What
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simplification?
 Has something changed?
What changes were made?
Why were these changes made?
When are these changes effective?
How will these changes impact me?
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Colorado Department of Health Care Policy and Financing
What to expect today
PASRR purpose
 Level I (Pre-Admission Screen)
 Level I Post-Admission update
 Resident Review/Status Change
 Diagnosis AND Triggers
 Surveys
 Questions Answered Session
 Discussions
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Colorado Department of Health Care Policy and Financing
• Background
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PASRR purpose
PASRR - Social Security Laws
The preadmission screening and residents review program
erected from the Ombnibus Reconcialtion Act of 1987 (OBRA)
under the Social Security Act as the governing rule for PASRR.
The program was designed to address housing MI/DD in NF
 PASRR - CMS (Centers for Medicare and Medicaid Services)
Today the national PASRR program is managed under
authority of the Centers for Medicare and Medicaid.
OIG has criticized CMS for failing to monitor PASRR.
States that participate with Medicaid must operate the federal
PASRR program as a requirement of their state plan.
Colorado Department of Health Care Policy and Financing
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PASRR purpose
PASRR
WHAT YOU MIGHT NOT KNOW
PASRR Operations Team
PASRR Technical Assistance Center
OIG Department of Justice
Association of PASRR professionals
PASRR and the Olmstead connection
PASRR/MDS coordination (October 2013)
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Colorado Department of Health Care Policy and Financing
PASRR purpose
operations & state agencies
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Operations (State Medicaid Agency) – HCPF
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Legal Responsibility to operate a PASRR program
Financial Responsibility
Reporting
Tracking
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Level II Evaluation and Determination Authority
 Mental Illness
(State Mental Health Authority) DHS:DBH
 Intellectual Disability (State Intellectual Disability Authority) HCPF
 PASRR final approval for NF care and service determinations
Determinations made by Level II authorities cannot be countermanded by SMA
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Colorado Department of Health Care Policy and Financing
PASRR purpose
operations by state authority
State PASRR program operations must meet
all CMS requirements
• LEVEL I EVALUATION - completed online by referral source
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State Medicaid Agency is responsible for Level I identification process
• LEVEL II EVALAUTION - completed by Level II evaluators
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State Mental Health Authority SMHA and State Intellectual Disability Authority SIDA
• RESIDENT REVIEW – completed by appropriate OBRA/SIDA
Level I Evaluations performed
24,240
2012
Level II Evaluations performed
1,310
2012
2012
Colorado Department of Health Care Policy and Financing
So What Changes were made?
• FORM SIMPLIFICATION PROJECT
PASRR contractor 2012
 Merge 3 Level I forms into 1
 Level I form online (December 2013)
 Create a Post Level I to reflect current and accurate PASRR
 Merge existing Status Change and Depression Diversions
(PASRR operations team 2012/2013)
 Create a Resident Review reflect current and accurate PASRR
 Post Dear Administrator Letter (spring 2014)
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Colorado Department of Health Care Policy and Financing
PASRR Level I
• PASRR Level I – State Medicaid Agency: SMA
• Must identify all individuals suspected of having
MI or ID. “TRIGGER”
• If Level I ‘tool’ is inadequate the state might be
in violation of its obligation.
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Objective to identify all possible triggers of PASRR
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Source: PASRR Technical Assistance Center
Colorado Department of Health Care Policy and Financing
PASRR Level I
• PASRR test positive = TRIGGER
Colorado PASRR refers to “positive” as a TRIGGER
 A TRIGGER results in clinical review, with few exceptions
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• PASRR 1.5
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(Clinical Review)
Whenever an individual has a positive TRIGGER, a state
reviewer/clinician evaluates the record to determine if
there is or is not a PASRR condition
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Yes_ refer for Level II or apply categorical/exclusions
No_ may admit with or without conditions
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Colorado Department of Health Care Policy and Financing
PASRR Level I
• PASRR Level I approved outcomes (final)
Non-Cert = screened and has no suspicion of MI/ID
 Approved no MI/ID = positive trigger was reviewed
and determined to have no suspicion of MI/ID
 Approved ‘time limited’ = has triggers, can admit,
meeting certain time limited criteria and must be
reassessed for suspicion of PASRR if individual
remains in NF post time limited approval.
 Refer for Level II = Full Level II evaluation and
determination required prior to admitting to facility
or upon status change
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Colorado Department of Health Care Policy and Financing
PASRR Level I
• PASRR Level I other outcomes (Not Final)
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Hold For Review =
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Held for clinical review (1.5)
Held for more information
Non-Cert Due to inconsistent information
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Narrative that does not match checked indicators
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Colorado Department of Health Care Policy and Financing
PASRR Level I
Post Admission Level I update
Intended to maintain current and accurate PASRR
 ONE
TWO-SIDED paper document
 New form
current and accurate Level I update by 10/01/14
 Update as necessary for
change of status (within 14 days)
 Retained in the resident medical record
 Usually precedes Resident Review/Status Change if
 Reason for
warranted
update and OBRA questions must be answered
 Must be signed and
dated by NF staff
Colorado Department of Health Care Policy and Financing
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PASRR Level I
Post Admission Level I update
Resident Demographics
 New Diagnosis
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Includes anxiety, panic disorder, somatoform, personality
disorders not previously screened
New Discovery of Intellectual Disability
Psychotropic medications given on a regular basis
New or worsened symptoms
Reason for update
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Has OBRA has been contacted
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Colorado Department of Health Care Policy and Financing
PASRR Level I post admission
Reason for Updated Level I is required and helps to identify
the need to contact your OBRA coordinator.
• Reasons that do not indicate to contact OBRA
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Admitted without required PAS
Incorrect PAS (nursing facility change medication change)
• Reasons to contact OBRA
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New or worsened Serious Symptom
New Diagnosis as indicated by section I
Psychiatric meds for dementia not on or over the Beers List
New category of psychiatric medication started
Expiration of time limited approval
Colorado Department of Health Care Policy and Financing
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PASRR Level I post admission
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Colorado Department of Health Care Policy and Financing
PASRR Level I post admission
Section VI Reason for
update must be answered
VI. Reason for Updated Level I
Admitted without required PAS
Incorrect or missing PAS
New or worsened Serious Symptoms
New diagnosis identified in Section I.
Psychiatric meds for Dementia not on or over the Beer’s list
New category of psychiatric meds started for non-organic condition
Expiration of time limited approval
Tip
Nursing Facilities must contact OBRA for
Any Selections that apply EXCEPT:
Incorrect or missing PAS
Admitted without PAS
Colorado Department of Health Care Policy and Financing
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PASRR Level I post admission
Nursing Facility must
indicate if the OBRA
coordinator has been
contacted as a result of
this PASRR review
Nursing Facility staff
signature indicates
PASRR review
complete
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Colorado Department of Health Care Policy and Financing
BREAK
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Colorado Department of Health Care Policy and Financing
PASRR Resident Review
(Status Change)
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PASRR Level II –State Mental Health Authority
PASRR Level II –State Intellectual Disability Authority
Resident Review ensures individuals’ needs are met
SMHA/SIDA retain authority over criteria used in
evaluating Resident Review
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OBRAs conduct a 1.5 review to determine PASRR condition
• SMA oversight ensures operations are compliant
• Best Practice produces false positives
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Source: PASRR Technical Assistance Center
Colorado Department of Health Care Policy and Financing
PASRR Resident Review
(Status Change)
Intent of NEW Resident Review/Status Change
• Integrates previous Status Change Review
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and Depression Diversion forms
Stronger identification of PASRR triggers
Clearly identifies date of compliance
Incorporates all federally required diagnoses
Triggers more closely align with those
identified on the Level I update
Colorado Department of Health Care Policy and Financing
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PASRR Resident Review
(Status Change)
• Providing Information to the OBRA
 OBRA
coordinator determines method for information
sharing (phone, fax, secure email)
 OBRA coordinator determines what information is
necessary to conduct a Resident Review/Status Change
 Once OBRA coordinator has all the information they
required from the SNF; OBRA coordinator has 3 business
to complete the review.
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Colorado Department of Health Care Policy and Financing
PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
OBRA personnel were trained on NEW Resident
Review/Status Change in February 2014.
Key Points:
• OBRAs perform a clinical review of the individual
based on information received by the NF.
• An OBRA review uses clinical judgment, and any
combination of signs/symptoms to assess a case.
• Doubling of antidepressant is no longer a trigger .
• Psychiatric Hospitalizations have been added.
Colorado Department of Health Care Policy and Financing
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PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
Diagnosis of Mental Illness
• New Diagnosis: anxiety, personality disorder, panic
disorder and somatoform need to be considered
through the same clinical lens.
• OBRAs job is to substantiate any changes.
• SNF job is to reconcile any differences in the
medical record using information from OBRA.
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Inconsistency between medical record and Level I
Requirement that information on Level I is current & accurate
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Colorado Department of Health Care Policy and Financing
PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
Diagnosis of Organic Condition
• Old SC form did not consider Organic Conditions
• New form provides opportunity to clarify organic
conditions that impact a persons presentation
Psychotropic Medications
• Monitoring medication is important to assessing
extenuating circumstances that could be impacting the
persons presentation and behaviors
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Pay attention to the dosages of medications
Be sure to use diagnoses and not just list symptoms of diagnosis
Colorado Department of Health Care Policy and Financing
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PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
OBRA OUTCOMES
Determination of the outcome depends on OBRAs findings.
Approved, NO MMI
No more action is required
Approved with follow up next quarter
Burdon to follow up is on Nursing Facility
Status Change, Approved MMI
Previous Level II completed and NO-NEW level II at this time
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Colorado Department of Health Care Policy and Financing
PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
OBRA OUTCOMES continued:
Refer for Level II
MMI transition to primary diagnosis of dementia
NEW MMI
Substantial change from previous Level II
Substantial deterioration in level of functioning NOT due to
organic or physical/medical condition
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Determination of the outcome depends on OBRAs findings.
Colorado Department of Health Care Policy and Financing
PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
• Determinations of outcome depends on
OBRA findings:
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Approved, NO MMI
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Approved with follow up next quarter
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NO MORE ACTION REQUIRED
Burdon to follow up is on Nursing Facility
Status Change, Approved MMI
Previous Level II
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No New LEVEL II required at this time
Colorado Department of Health Care Policy and Financing
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PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
Resident Review- OBRA indication of noncompliance
• Status Change
Failure of SNF to refer for status change within 14 days
 Failure of SNF to provide necessary information (timely)
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• Pre-Admission Screen (PAS)
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Original PAS does not indicate triggers, where clearly noted
Person admitted without PAS
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Colorado Department of Health Care Policy and Financing
PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
OBRA review completion
• OBRA will send the signed and completed
NEW Resident Review/Status Change form to
the Nursing Facility to maintain in the record.
• OBRA will keep a copy for the Mental Health
Center’s PASRR – OBRA office.
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Colorado Department of Health Care Policy and Financing
PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
Severe Anxiety –
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Added to list of triggers in early 2014
If diagnosis captured and screened on PAS, no
need for review
If not captured on PAS, needs reviewed for
severity & need for treatment.
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Colorado Department of Health Care Policy and Financing
PASRR -Diagnosis and Triggers
Overview OBRA TRAINING (02/2014)
Determining Severity of Anxiety –
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Level I -completers are required to identify
“suspicion” of mental illness.
Level 1.5 -Masspro evaluator determined
seriousness and whether Level II required)
Level II -Evaluates severity, impact on
functioning and treatment
recommendations.
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Colorado Department of Health Care Policy and Financing
PASRR Resident Review/Status Change
OUTCOME:
Approved, no MMI (no Level II required)
Approved with follow up next quarter (does not require Level II)
Status Change, Approved MMI (does not require new Level II)
Refer for Level II (Level II attached to this document)
OBRA review will
determine OUTCOME
REASON FOR OUTCOME AND ANY IDENTIFIED NON-COMPLIANCE:
SEPs – If OBRA indicates COMPLIANCE the date used
for PASRR approval is the date of the original Level I
OBRA INDICATED COMPLIANCE
OBRA INDICATED NON-COMPLIANCE DUE TO:
Status Change
PAS
If non-compliant, PASRR Compliance/Effective Date:
CMHC/PASRR Evaluator:
Date:
If non-compliance
is indicated the
EFFECTIVE DATE
OBRA fills in is the
date of PASRR
approval
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OBRA MUST SIGN
Colorado Department of Health Care Policy and Financing
PASRR Resident Review/Status Change
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Colorado Department of Health Care Policy and Financing
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Colorado Department of Health Care Policy and Financing
SURVEY
• Survey is the Regulatory Arm of PASRR
OIG requirements for CMS oversight
 Colorado Survey Authority = DPHE (public health)
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• Survey process relies on evidence
Evidence of PAS
 Evidence of RR for suspicion of change (MDS)
 Evidence of Specialized Service
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Colorado Department of Health Care Policy and Financing
SURVEY-EVIDENCE
Record Keeping Documentation
“There should be no information in the individual’s
record to suggest that their condition has changed
markedly – for better or worse – since the last
evaluation was conducted”
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Colorado Department of Health Care Policy and Financing
SURVEY-Form Simplification
DPHE – has been notified of upcoming change
DPHE has worked with PASRR ops on the changes
 Trained on what to look for regarding PASRR
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After October 01, 2014 facilities might be
cited regarding these changes
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Colorado Department of Health Care Policy and Financing
BREAK
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Colorado Department of Health Care Policy and Financing
PASRR- Level I PAS/RR
Questions and Answers session
Colorado PASRR FACTS
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The current approved Level I (PAS) is the online COPASRR.com
Nursing homes cannot complete or accept an old paper Level I PAS
New Level I review update addresses NEW diagnosis
Nursing Home bears final responsibility for Level I accuracy
“Emergency” admits are not exempted from preadmission
screening (emergency means immediate placement for life safety)
• The OIG recognizes Hospital discharge planners and NF conduct PAS
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Parties need to cooperate at the local community level to achieve smooth PAS process
• Readmissions within 30days are only subject to a Resident Review
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Level I update is appropriate for completion
Colorado Department of Health Care Policy and Financing
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PASRR- Level I PAS/RR
Questions and Answers session
Colorado PASRR FACTS
• Nursing Facility placement can be changed in the ONLINE system by
referring Site Admin within 72 hours of FINAL approved outcome
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NF can complete a Level I update if designated facility changes
Hospital Exemption, only true exemption according to PTAC
Time Limited categories are not exemptions
HCBS respite DOES NOT REQUIRE PASRR (not a NF admission)
PACE RESPITE to LTC requires contacting OBRA for RR if applicable
HCBS respite to LTC requires Level I completion by SEP
New RR/SC replaces Depression Diversion
Level II evaluations need to be sent to Masspro
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Colorado Department of Health Care Policy and Financing
PASRR- Level I PAS/RR
Questions and Answers session
Colorado PASRR FACTS
• PASRR Resident Review: The state must periodically review the
MI/ID status of NF residents.
• Resident Reviews/Status Change must be referred when there is a
change or suspected change as indicated by post level I update
 SEPs may require NF to contact OBRA for RR prior to approval
• Resident Reviews/Status Change must be completed by a state
approved reviewer (Colorado OBRA or OBRA coordinator/SIDA)
• Nursing facility to Nursing facility transfer need only a Resident
Review (including Level II)
 Transfer (initial Level I, RR, Level II and determination letter)
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• PTAC says the goal is to error on the side of positives
Colorado Department of Health Care Policy and Financing
Frequently Asked Questions
• Is there a time frame for NF to review PASRR?
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Yes, time frame is between July 01 and October 31, 2014
• What should SEPs do if there is a discrepancy?
SEPs should refer NF to OBRA and follow RR/SC form
• Is a new Level I needed if meds change before discharge.
 A Level I update after admission is appropriate in this case.
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OBRA will need to be contacted only if indicated by Reason for Update
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Notify state Medicaid Agency if there is a recurrent issue.
• Does a follow up next quarter outcome require RR/SC
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Yes- follow up next quarter is a time limited approval
• Who completes the Level I- online {Colorado Rule}
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SEPs/Medicaid – Hospitals/Not Medicaid – NF/Pay source  8.401.184
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Colorado Department of Health Care Policy and Financing
Level I flowchart PTAC
excerpts
Level I process FLOWCHART
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Colorado Department of Health Care Policy and Financing
Level II flowchart PTAC
.
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Colorado Department of Health Care Policy and Financing
Resident Review flowchart PTAC
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Colorado Department of Health Care Policy and Financing
PASRR DISCUSSION
Quality Monitoring
• Quality Monitoring in PASRR is coming…
 Improves
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outcomes for individuals
Placement options and review of services for Level II
 Supports
effective and efficient process
Identifies non-compliance or needed improvement
 Likely to
follow NF(QIS) and HCBS(QIS)
 Some states already using MDS data to shape
their monitoring program and required reporting
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Colorado Department of Health Care Policy and Financing
PASRR DISCUSSION
Quality Monitoring
• Quality Monitoring in PASRR–Data elements
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Informative Examples
Level I – Number of completed Level I
Level I -- # and percent of positives
Level II -- # and percent of positives that result in Level II
Level II -- # and percent of positive Level II
Resident Review – Number of Resident Reviews
Average length of time in days to complete reviews
Number and percent of PASRR placements in the
community
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Colorado Department of Health Care Policy and Financing
PASRR- Level I PAS/RR
Questions and Answers session
AUDIENCE ASK QUESTIONS
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Colorado Department of Health Care Policy and Financing
PASRR- RESOURCES
• State Program Authorities
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Casey Dills ODonnell
State PASRR program administrator
303-866-2148/ [email protected]
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Ann Seanor
State Mental Health Authority
303-866-7143/303-895-0790 [email protected]
 Barb Rydell
State Intellectual Disability Authority
303-866-5157 [email protected]
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Colorado Department of Health Care Policy and Financing
Our Mission:
Improving health care access
and outcomes for the people
we serve while demonstrating sound
stewardship of financial
resources
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Colorado Department of Health Care Policy and Financing
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Colorado Department of Healthcare Policy and Financing
Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources