PASRR Redesign Overview Implementation Date May 24, 2013 Revised 5.20.2013

PASRR Redesign OVERVIEW The Pre-Admission, Screening and Resident Review (PASRR) process is a federally mandated process that is applied to all individuals who are seeking placement in a Medicaid-certified Nursing Facility (NF) - regardless of the funding source for the individual. The PASRR Evaluation must be administered to: Identify individuals with a mental illness, intellectual disability, or developmental disability, Determine if an alternative placement outside of a nursing facility is possible, Collect information to determine if the person could benefit from specialized services, Collect information to help determine if there is medical necessity for placement in a nursing facility. PASRR is a federal program that is not optional for States The process applies to anyone seeking admission to a Medicaid-certified NF 4 Goals – Identify MI and IDD, Make alternative placements when possible, determine if specialized services are indicated, and (in the case of persons with MI) determine if Medical Necessity exists. Revised 5.20.2013

PASRR Redesign OVERVIEW Cont’d Texas is changing the current PASRR process and this has specific implications for all Referring Entities such as Hospitals, Physician’s Offices, Families and for the Local Mental Health Authority(LMHA) and Local Authority (LA). These changes are in response to Federal notification of non-compliance with existing PASRR regulations. DADS, DSHS, and HHSC have been collaborating for well over one year to design these changes, have them approved by CMS, and to develop the IT infrastructure to support the new process. Why the change? Federal notification of non-compliance Large sweeping changes in the way PASRR is conducted. Considerable collaboration between HHSC, DADS, and DSHS Target date for implementation is May 24, 2013 Revised 5.20.2013

PASRR REDESIGN CONT’D The PASRR program is under the purview of the Department of Aging and Disability (DADS). The related program rules are in the “40 Texas Administrative Code, Part 1, Chapter 17”.The final rule was published in the Texas Register on May 17, 2013. The State has also been working with THA and DSHS Hospital Regulatory to disseminate information about the new process. The implementation date for the new process is May 24, 2013. Upon implementation, the NF will no longer accept a person for admission without a PL-1 screening. Revised 5.20.2013

Glossary LMHA - Local Mental Health Authority refers to the agencies that contract with the state to provide services for persons with mental illness. LA - Local Authority refers to the agencies that contract with the state to provide services for persons with intellectual, developmental disabilities or a related condition. RE – Referring Entity such as hospital, physician office, family member, home health agency, hospice NF – Nursing Facility MI – Mental Illness ID – Intellectual Disability DD/RC – Developmental Disability or Related Condition Revised 5.20.2013

PASRR Current vs. New Process CURRENT PROCESS NEW PROCESS There is no PL 1 screening form in place. The referrals are made by DSHS or DADS after the individual is already admitted to the NF. The Referring Entity (RE) will perform the PL-1 screening and provide a copy of the completed PL-1 form to the NF or LMHA or LA to be entered into the Texas Medicaid Healthcare Partnership online portal. The PASRR Level II has focused solely on the issues of Mental Illness and the desire for alternate placement. The PE will include evaluation elements relating to the Medical Necessity for NF Placement. The PE may be completed by a LMHA or LA staff who has been trained in the use of the instrument. Individuals are admitted to the Nursing Facilities (NFs) and are then evaluated to determine if specialized services are needed or if alternative placement is possible/available. Individuals meeting certain criteria must have a PE completed prior to admission to the NF. This means that the PE may occur in a number of locations such as hospitals, assisted living facilities, home and other community-based locations. Revised 5.20.2013

PASRR Current vs. New Process CURRENT PROCESS NEW PROCESS* The time taken to complete the PASRR Evaluation (Level II) has ranged from days to months. The PE must be initiated by the LMHA or LA within 72 hours of receipt of the PL-1. The NFs and Referring Entities coordinated to determine if a particular NF was capable of meeting the needs of an individual prior to placement. The LMHA or LA will collaborate with the Referring Entity and NFs prior to admission to ensure that the selected NF is capable of meeting the needs of the individual. Revised 5.20.2013

Hospital’s Responsibilities as a Referring Entity Begin Discharge Planning on Day 1 of Admission for all Patients When to complete a PL 1 form: If NF placement is anticipated as part of the discharge plan, hospitals must complete the Level I screening for an individual seeking admission into a nursing facility, unless the individual is being admitted to the same facility in which the individual resided prior to hospitalization, in which case the nursing facility may complete the Level I screening. Revised 5.20.2013

Hospital’s Responsibilities as a Referring Entity continued If the PL-1 screening does not indicate that the person is suspected of having MI / ID or DD/RC, the completed PL-1 must be forwarded to the NF with the individual. (The PL 1 would be considered negative. No further action is required by the RE- hospital.) NOTE: The NF will enter the PL 1 screening into the TMHP online portal. The hospital as a referring entity does not have access to the TMHP portal. Revised 5.20.2013

Hospital’s Responsibilities as a Referring Entity continued: If the PL-1 does indicate that the person is suspected of having MI/ID or DD/RC the RE (hospital) must proceed with the appropriate process based on the results of the PL-1. The individual with a positive PL 1 will be categorized into one of the following PASRR processes: NF Admission process for Exempted Hospital Discharge Expedited NF Admission for Hospital Discharge; or Pre-Admission (PASRR Evaluation – PE) process Revised 5.20.2013

Exempted Hospital Discharge for NF Admission This type of admission process to the NF is met when an individual is likely to require less than 30 days of NF services for the condition for which they are hospitalized. (Example – hip replacement and going to skilled level of care for rehabilitation) A physician must certify (via signature) the above. There is no specific form to document the information. The documentation must be in the medical record, in the physicians progress notes for example. In the case of Exempted Hospital Discharge, a PE is not required. If the individual ends up staying in the NF longer than 30 days, LMHA/LA will receive an alert through the TMHP system requesting a PE be completed. Note: The NF will enter the PL 1 screening into the TMHP online portal. The hospital as a referring entity does not have access to the TMHP portal. Revised 5.20.2013

Expedited Hospital Discharge for NF Admission Process EXPEDITED ADMISSION CATEGORIES IF AN INDIVIDUAL MEETS ANY OF THE FOLLOWING CATEGORIES, THE INDIVIDUAL CAN BE ADMITTED TO THE NF.   NO OTHER PASRR ACTIVITIES NEED TO BE COMPLETED PRIOR TO ADMISSION to the NF. Does this individual meet any of the following categories for an expedited admission into the nursing facility?     Yes        No (If yes, please check one category below)  1.  Convalescent Care:  Individual is admitted from an acute care hospital to a NF for convalescent care with an acute physical illness or injury which required hospitalization and is expected to remain in the NF for greater than 30 days.  (Medical Diagnosis such as Diabetes, CHF, CRF, Decubitus or Wounds, Traumatic Injuries)  2.  Terminally Ill: Individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.  An individual’s medical prognosis is documented by a physician’s certification, which is kept in the individual’s medical record maintained by the nursing facility.   3.  Severe Physical Illness: An illness resulting in ventilator dependence or diagnosis such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, congestive heart failure, which result in a level of impairment so severe that the individual could not be expected to benefit from specialized services.  (individual is unable to participate or benefit from services due to the level of impairment) Revised 5.20.2013

EXPEDITED ADMISSION CATEGORIES Expedited Hospital Discharge for NF Admission Process EXPEDITED ADMISSION CATEGORIES IF AN INDIVIDUAL MEETS ANY OF THE FOLLOWING CATEGORIES, THE INDIVIDUAL CAN BE ADMITTED TO THE NF.   NO OTHER PASRR ACTIVITIES NEED TO BE COMPLETED PRIOR TO ADMISSION to the NF.  4.  Delirium: Provisional admission pending further assessment in case of delirium where an accurate diagnosis cannot be made until the delirium clears. (Delirium may be caused from electrolyte imbalance, UTI, other medical conditions)  5. Emergency Protective Services: Provisional admission pending further assessment in emergency situations requiring protective services, with placement in the nursing facility not to exceed 7 days.  6. Respite: Very brief and finite stays of up to a fixed number of days to provide respite to in-home caregivers to whom the individual with MI or ID is expected to return following the brief NF stay.  7. Coma:  Severe illness or injury resulting in inability to respond to external communication or stimuli, such as coma or functioning at brain stem level. Revised 5.20.2013

Expedited Hospital Discharge for NF Admission Process Cont’d If the Expedited Admission criteria are met, the completed PL -1 form is sent to the NF with the individual and no further action is required by the RE- hospital. The NF will enter the PL-1 into the TMHP system that alerts the LMHA/LA to complete a PASRR Evaluation for the individual. Note: The hospital staff do not have access to the TMHP portal. Revised 5.20.2013

NF Pre-Admission Process PL 1 screening identified or suspected the individual has a diagnosis of MI/ID/ or DD/related condition -The individual’s condition did not meet an exempted or expedited discharge criteria to the NF; therefore the NF Pre-Admission Process is required. If the PL 1 indicates the MI only – PL 1 is faxed to the LMHA If the PL 1 indicates ID, DD or a related condition – PL 1 is faxed to the LA Once the PL 1 is faxed to the LMHA or LA -(LMHA or LA is responsible for submitting the PL1 into TMHP system) • LMHA or LA responds to the PL 1 requests within 72 hours of the receipt of the referral for the LMHA or LA • LMHA or LA has 7 days from the receipt of the referral to enter the PE into the TMHP system (Referring Entity and the LMHA or LA must retain the faxed PL1 to verify date and time of receipt) Revised 5.20.2013

Alternate Placement This PASRR redesign includes a process for those individuals requesting alternate placement . Even if the individual meets one of the other types of PASRR processes; they may still request alternate placement. In most cases the LMHA or LA staff and the referring entity will be aware of the options available in the community for the individual. LMHA or LA should be notified via phone if the individual is requesting alternate placement LMHA or LA performs Section E on the PL 1 screening form (This section of the form maybe completed by the RE if known at the time of the screening and prior to faxing the PL 1 to the LMHA or LA) The LMHA or LA will collaborate with the referring entity to provide assistance to the individual prior to admission to the NF, or after admission to the NF if the individual is still interested in seeking alternate placement. Revised 5.20.2013

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Key Points: Implementation is May 24, 2013. If NF placement is anticipated as part of discharge plan, hospitals must: Complete the PL 1 screening form for each individual who may be referred to a Medicaid-certified NF regardless of payer source of the individual. The NF will NOT accept admission without a completed PL-1 upon the implementation of the new process. Revised 5.20.2013

RESOURCES PL1 final form and PASRR Evaluation (PE) - PDFs are posted on the TMHP Website at the following link: http://www.tmhp.com/Pages/LTC/ltc_forms.aspx Related conditions link on the DADS’ Website: http://www.dads.state.tx.us/providers/guidelines/ICD-9-CM_Diagnostic_Codes.pdf Contact DADS for any questions related to Nursing Facilities and admissions. pasrr@dads.state.tx.us Revised 5.20.2013

PASRR Information for Referring Entities: Check DSHS website has information for the Referring Entities Sign up for email updates as changes occur on the website www.dshs.state.tx.us/mhsa/PASRR Revised 5.20.2013

PASRR Information: PL -1 Screening form and PL -1 instructions for the Referring Entities are posted on the TMHP website. http://www.tmhp.com/Pages/LTC/ltc_forms.aspx Webinars for Referring Entities will be posted on DSHS website at http://www.dshs.state.tx.us/mhsa/pasrr/ Future webinars will be scheduled in June, July and August. Type your questions during the webinar or email to pasrr@dshs.state.tx.us – the answers to the questions will be posted on the DSHS website and updated each Friday. Revised 5.20.2013

PASRR Contacts & Info. DSHS Lisa Fallon (512) 206-5039 lisa.fallon@dshs.state.tx.us or pasrr@dshs.state.tx.us DSHS PASRR Web Page www.dshs.state.tx.us/mhsa/PASRR DADS Heather J. Cook (512) 438-5233 Heather.Cook@dads.state.tx.us or pasrr@dads.state.tx.us DADS PASRR Web Page www.dads.state.tx.us/providers/pasarr/redesign Revised 5.20.2013