Pasrr and Level of Care Screening

TN PASRR & LOC

PROVIDER POLICY & PROCEDURES

PASRR AND LEVEL OF CARE SCREENING

TENNESSEE LONG-TERM CARE SERVICES

Provider Manual

MANUAL DEVELOPMENT DATE: 9.13.2016
MOST RECENT REVISION: 12.0611.4.2016

The policies and procedures in this document are approved and signed by Operations Director prior to posting.

Ascend is recognized nationally as a leader in providing outstanding clinical processes, information systems and superior management solutions to help our customers enhance their
healthcare delivery systems.

TABLE OF CONTENTS

TABLE OF CONTENTS

TABLES

ABOUT ASCEND

Have Questions?

ABOUT LEVEL OF CARE

Ascend’s role in TN long-term care services

Additional Resources

ABOUT PASRR

1.0 PASRR LEVEL I SCREENING PROCESS

1.1 Who receives a Level I?

1.2 Who submits a Level I screen?

1.2.1 Level I Draft Screens, Turnaround Time, and Holding for Information

1.3 Level I Outcomes

1.4 The Neurocognitive Disorder (Dementia) Exclusion

1.5 Exempted Hospital Discharge (EHD)

1.6 Categorical Determinations

1.6.1 Convalescent Care Categorical

1.6.2 Respite Categorical

1.6.3 Terminal Illness

1.6.4 Severe Physical Illness

1.6.5 Neurocognitive Disorder (Dementia) and ID

2.0 LEVEL OF CARE SCREENING OVERVIEW

2.1 What is the purpose of the LOC screen?

2.2 Submitting a Level of Care (LOC) screen

2.2.1 Who receives a LOC screen?

2.2.2 LOC Draft Screens, Turnaround Time, and Holding for Information

2.3 LOC Criteria Guidelines

2.3.1 Safety Determination Requests

2.3.2 Required Documentation

2.4 Clinical Review & Outcomes

2.5 Printing & Distributing Outcome Letters

3.0 PASRR TRACKING REQUIREMENTS

3.1 Transfers and Out-of-State Referrals

3.1.1 Inter-facility Transfers

3.1.2 Out-of-State Transfers

3.2 Weekend, Holiday, & After-Hour Screenings

4.0 GENERAL SYSTEM INFORMATION

4.1 Getting Started in Ascend’s Web-based System

4.1.1 User Registration & Maintenance

4.2 Important Information About Electronic Screening Submission

4.2.1 Multi-facility Users

4.2.2 Draft Screen Expiration

5.0 HAZARDOUS CONDITIONS & NATURAL DISASTER

TABLES

Table 1: LOC Submission Requirements by Provider Type

Table 2: LOC/Level II Outcomes

Table 3: User Roles in Ascend’s Web-based System

ABOUT ASCEND

Ascend Management Innovations (formerly Ascend Management Innovations)originated in 1998as a pioneerin designing innovativehealthcaremanagementsolutions forprogramsserving individuals with complexdiagnosticprofiles. Since 2000, Ascend has been partnering with state agencies to provide individualized assessment services for individuals with mental health and/or intellectual and developmental disabilities. Wespecializein incorporating evidence-based practicesinto public sector healthcaremanagementthrough acombination ofinformation technologies, quality improvementandmanagementinitiatives,serviceoversight, providertraining, and managementofhealthcaredatasets.

Ascend aims to make a difference in the lives of persons with disabilities by providing superior assessment services that effectively capture the individual’s personal needs and goals and enrich the person-centered planning process. Ascend’s leadership team offers extensive experience in managing assessment services. Together with the contract staff and independent contractors, Ascend is able to provide individualized, comprehensive assessments to identify areas of focus to best meet the individual’s needs.

Have Questions?

For questions about Ascend’s web-based system, including system access, password assistance, etc. .

For questions about PAEs, call the Long Term Services and Supports (LTSS) Help Desk at 1.877.224.0219.

For questions about financial eligibility or Medicaid applications, call TNHC at 1.855.259.0701.

For questions about technical support between Ascend and TMED, email and type TMED/Ascend Services Issue in the subject line of the email. This inbox is monitored between 8am and 5pm CST. If there is an urgent need outside of regular hours, and the provider has already sent an email, contact HPE TennCare IT Operations Help Desk at 615.507.6200 and request dispatch to Level II support for the SOA team. If a response is not received, providers can call this number back and request an escalation to Christie Bautch.

For more information about Ascend, please visit our website at

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ABOUT LEVEL OF CARE

Ascend works with TennCare, the Department of Mental Health and Substance Abuse Services (DMHSAS), the Department of Intellectual and Developmental Disabilities (DIDD), and healthcare providers to conduct level of care (LOC) and length of stay (LOS) screening services to ensure appropriate placement for applicants and residents of Medicaid-certified nursing facilities. The main objectives of the LOC and LOS screening process are to:

• Determine whether an individual’s NF stay is expected to be short or long term,
• Ensure that the appropriate criteria are applied for determining NF LOC and LOS in accordance with the individual’s payment method (i.e. criteria for private pay vs. Medicaid), and
• Identify each individual’s interest in, and potential for, transition or diversion to an alternative setting for receiving services.
• Managed Care Organizations (MCOs) and Ascend will work together to monitor, coordinate, and promote community options through notification of transition and diversion candidates.

Ascend’s role in TN long-term care services

Ascend provides and maintains a web-based assessment platform which hospitals, NF, AAADand MCO providers use to complete the federal PASRR Level I screen and in some cases the medical eligibility application. This platform allows providers to quickly and securely:

• submit electronic Level I screens,
• submit electronicmedical eligibility screens,
• view outcomes,
• print notification letters, and
• update placement discharge and admission information for location tracking.

Additionally, Ascend’s web-based system communicates with TMED, the State’s electronic Medicare/Medicaid management system to ensure increased efficiency of the PASRR and Level of Care process.

Ascend also provides staffing for the Tennessee project to offerprovider support, answer questions, and ensure quality assessments.Ascend’s Project Support Specialists (PSS) assist with answering non-clinical questions. The PSS helps answer provider questions about workflow, timelines, etc.; provides direction to providers as needed; and routes technical questions about the website to Ascend’s IT team as needed.

Ascend’s Clinical Reviewers provide clinical review of all Level I screens that do not result in an immediate approval for NF placement, as well as Level of Care submissions. Clinical Reviewers will clinically review screens as well as any supporting documentation, and provide the relevant persons with a written outcome, which the provider prints directly from Ascend’s web-based system. Clinical Reviewers may also contact submitters within the web-based system to seek clarification or additional information in order to make an appropriate determination for the individual.

Providers can begin a screen and save the screen without submitting it, creating a “draft screen” that is accessible for up to 24 hours. This allows providers to save and return to the draft screen later to make corrections, and/or upload/fax documentation before submitting the screen. Providers can also withdraw draft and submitted screens when a screen is no longer necessary (e.g. the individual expires, discharges to a community setting, admits to a NF that is not Medicaid-certified, etc.).

Please note all screens are subject to quality review by one of Ascend’s Clinical Reviewers.

Additional Resources

To access trainings, frequently asked questions, and other helpful resources about PASRR, Level of Care, and Ascend’s web-based system, visit the Tennessee PASRR User Tools page of Ascend’s website at

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ABOUT PASRR

Background

PASRR stands for Preadmission Screen and Resident Review. PASRR began in the 1980s as part of an initiative to improve nursing facility care. In 1987, the Omnibus Reconciliation Act of 1987 (OBRA-87), known as the Nursing Home Reform Act, was enacted. The purpose of OBRA-87 is to protect individual rights, improve quality of care, and improve quality of life of those who need nursing facility care.

A portion of this Act, known as PASRR, clarifies the role that nursing facility providers have in addressing behavioral health needs of nursing facility residents. The goal of PASRR is, in part, to:

• Identify individuals who have or might have a serious mental illness (SMI), intellectual/developmental disability (IDD), or a condition related to intellectual disability [referred to as related condition (RC)], based on the information available. Known as the Level I, this is a short screen that seeks to answer the question: “Does this person have a known or suspected serious mental illness, an intellectual disability and/or a related condition?” If the answer is no, then the person may be admitted to a nursing facility if he or she meets the State’s criteria for nursing facility level of care. If the answer is yes or maybe, further evaluation is required before the person can go into the nursing facility. Per federal requirements, every person who is seeking admission to a Medicaid-certified NF must be screened for the presence of an MI, ID or RC condition before the provider can admit him or her into a Medicaid-certified nursing facility prior to admission.
• Determine services and supports persons with MI/ID/RC need. The PASRR Level II evaluation process identifies the rehabilitative or specialized services that the person requires. Nursing facilities are responsible for planning for and delivering—or arranging for the delivery—of all rehabilitative services that are identified through the PASRR Level II evaluation process.
• Determine the most appropriate setting for persons with MI/ID/RC. There are two main considerations in determining appropriateness: what is the least restrictive setting necessary that also meets the person’s needs.

In Olmstead v. L.C. (1999), the US Supreme Court deemed mental illness to be a form of disability protected under the Americans with Disabilities Act. The Supreme Court held that persons with mental disabilities have the right to live in the community rather than in an institution when it is the person’s wish to live in the community and the State’s treatment professionals have deemed community-based services appropriate for the individual’s needs. Additionally, the Supreme Court held that unjust segregation based on a disability is discrimination.

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Federal Requirements of PASRR

The PASRR program is mandated by the Centers for Medicare and Medicaid (CMS) and ensures that persons with MI/IDD/RC receive the appropriate placement and services necessary to meet their needs.

When a person with MI/IDD/RC is approved for nursing facility admission, the nursing facility providers must address both the medical and behavioral needs of residents. Before admitting the individual to their facility, the receiving facility should review the PASRR outcome notification letter to ensure they are able to provide the services and supports that are identified through the PASRR process.

The PASRR process must be completed prior to admission, and whenever an individual experiences a significant change in condition, referred to as a Status Change review.

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Who is evaluated through PASRR?

Persons with Serious Mental Illness (SMI)

PASRR is designed to identify individuals with a serious mental illness. The Level I screen gathers information about the individual’s mental health diagnoses, the person’s symptoms and the intensity/severity of symptoms, and the degree to which the condition/symptoms have impacted the person’s life and well-being.

The federal definition for SMI is:

• Diagnosis of a major mental illness, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depression, psychotic disorder, panic disorders, obsessive compulsive disorder and any other disorder which could lead to a chronic disability which is not a primary diagnosis of neurocognitive disorder (dementia).
• Duration: significant life disruption or major treatment episodes within the past two years and due to the disorder. This does not necessarily mean that the individual was hospitalized. This might include, for example, a person whose mental illness exacerbated to the extent that critical resource adjustments (such as increased case management services, increased monitoring, etc.) would have been indicated (regardless of whether they were identified or delivered). Examples of the types of intervention needs which may have occurred, regardless of whether or not services were delivered, include (but are not limited to):
• Psychiatric treatment more intensive than outpatient care (e.g., partial hospitalization, inpatient psychiatric hospitalization, crisis unit placement) within the past two years; or
• A major psychiatric episode; or
• A suicide attempts or gestures; or
• Other concerns related to maintaining safety.
• Disability: referred to as Level of Impairment in regulatory language, disability is characterized by active behavioral health symptoms within the preceding six month period which significantly interfere with the individual’s ability to interact interpersonally, concentrate, follow through with goals or needs, and/or adapt effectively to change. Simply, this means that the individual has experienced chronic or intermittent symptoms over the preceding 6 months which have impacted his or her life.

How would a person with a first time episode of serious depression be assessed under these criteria?
To answer that, let’s first look at the data. Current studies identify a range of anywhere from 19%-55% of persons in NF populations who experience mental disorders. Data also tells us that elders are the most likely to attempt suicide and to use lethal means to accomplish suicide than any other population. Although persons living in NFs are less likely to attempt suicide through violent means, they have high levels of suicidal ideation. Moreover, many of these persons die from indirect suicide than from direct suicidal behavior (through self-destructive behaviors such as refusing to eat or refusing life-sustaining medications).
While PASRR does not target persons who have a brief episode of depression, if the depression is more severe than—or lasts longer than—a typical grief reaction, it is important that you provide sufficient information for Ascend’s clinicians to determine whether treatments should be identified through the PASRR process to address and improve the individual’s symptoms. As a general guideline, if an individual experiences a depressive episode which lasts longer than three months, this could be considered as a sign of a potential first-time episode of serious depression.

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Persons with Intellectual Disability

Intellectual Disability (ID) is defined in the Diagnostic and Statistical Manual, Fifth Edition as a disorder that includes intellectual and adaptive functioning limitations with an onset in the developmental period (childhood or adolescence), prior to age 22. Intellectual disability may be associated with other conditions, such as a genetic syndrome, or traumatic brain injury (TBI) sustained during the developmental period. Three criteria must be met:

• Deficits in intellectual functioning (reasoning, abstract thinking, learning, etc.)
• Deficits in adaptive functioning that require ongoing support (social skills, relating to others, personal independence, etc.)
• Deficit onset during the developmental period

The level of severity of an individual’s intellectual disability is based on adaptive functioning in three domains—Conceptual domain, Social domain, and Practical domain—and is classified in one of four ranges: Mild, Moderate, Severe and Profound.

One key challenge for conducting evaluations is confirming that lowered cognitive levels are developmentally related, and do not result from other medical causes (e.g., stroke, TIA, accidents, or injuries) during adulthood. Because formalized testing was less normative in rural areas for elderly individuals with IDD, a responsibility of the evaluation process is to research developmental information and medical history to confirm developmental onset if that has not been done previously.

If the individual with IDD/RC also has a diagnosis of neurocognitive disorder (dementia), it is important to document as clearly as possible the extent of the neurocognitive disorder (dementia). If the neurocognitive disorder (dementia) is progressed, s/he may be found to be appropriate for NF care by virtue of the progression of the neurocognitive disorder (dementia) condition. In order to determine progression of neurocognitive disorder (dementia), it is critical that information be gathered to reflect the individual’s pre-morbid state (e.g., what was the individual’s functioning before the onset of neurocognitive disorder (dementia) versus his/her current functioning?). Generally, that information is best obtained from family or other caregivers who have known the individual well. Confirmation that a neurocognitive disorder (dementia) diagnosis is primary may require substantiation by neurocognitive testing, CT scan, MRI, etc. Refer to section 1.3.1b Neurocognitive disorder (dementia) Exemption for more information.

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Persons with a Related Condition (RC)

Related Condition (RC) is a federal term referring to conditions where service or treatment needs are similar to those of individuals with intellectual disability. The evaluation for this population must specifically incorporate information sufficient to confirm substantial limitations in three or more major areas of life activity, in addition to confirmation of developmental onset of the condition (prior to age 22) as specified under §435.1009.

Individuals with a related condition have service or treatment needs similar to individuals with intellectual disability. RC is defined as a severe, chronic disability that meets all of the following conditions:

• Is attributable to cerebral palsy, epilepsy, or any other condition other than mental illness, found to be closely related to intellectual disability (ID) because it results in impairment of general intellectual functioning or adaptive behavior similar to ID and requires treatment or services similar to ID
• Is present prior to age 22
• Is expected to continue indefinitely
• Results in substantial functional limitations in three or more of the following major life activities:
• Self-care
• Understanding and use of language
• Learning
• Mobility
• Self-direction
• Capacity for independent living

Note:Diagnosis alone is not a qualifier for a RC.

1.0 PASRR LEVEL I SCREENING PROCESS

1.1 Who receives a Level I?

A Level I screen is required for all individuals seeking admission to a Medicaid-certified nursing facility, regardless of how the person is paying for their stay (i.e. Medicare/Medicaid, private insurance, etc.). Level I screens are submitted via Ascend’s web-based system.