One of the most important outcomes of PASRR is that individuals receive the services identified during the PASRR process as necessary to address their mental illness and/or intellectual or developmental disability. Many state PASRR programs have found this to be one of the greatest challenges that they encounter. Addressing this was one of the primary goals in Indiana as they developed their PASRR program.
Assigning responsibility and accountability was a key first step in ensuring the provision of appropriate services. Indiana relied on federal and state regulations that clearly indicated that once a nursing facility has admitted an individual the facility assumes the responsibility for providing, or arranging for, services to meet the needs of the resident. This applies equally to mental health needs as well as physical health disorders. Once this standard was established the state implemented the following processes to achieve this goal:
1. Indiana has had pre-admission screening for all Medicaid-certified nursing facility applicants since the early 1980’s. Each of the state’s area agencies on aging (AAA) has a pre-admission screening (IPAS) office which serves as the single point of entry for the state’s long-term care system. When PASRR came along it made sense to utilize the IPAS office as the local coordinating entity for the PASRR process. IPAS reviews all Level I screens and decides if a Level II is warranted. If so it is assigned to the local community mental health center (CMHC) for PASRR MI Level II evaluations or a diagnostic; an evaluation team comprised of psychologists, nurses, and social workers, undertake PASRR ID/DD Level II reviews. Upon completion, the Level II is returned to the IPAS office, which reviews the evaluation, makes the appropriate determinations, and provides necessary notifications. The area agencies on aging also contain the long-term care ombudsman program and maintain a relationship with the adult protective services program. The combination of these offices and other programs within the AAA provides another opportunity for monitoring service delivery in nursing facilities. Several of the IPAS offices and/or CMHCs have provided PASRR training to hospital and nursing home staff members. The IPAS/PASRR Unit in the state unit on aging provides oversight of the IPAS offices.
2. In Indiana the State Department of Health has the responsibility for licensing and surveying nursing facilities. The surveyors are provided training in PASRR, which includes an explanation of the purpose of PASRR, the state’s PASRR process, what to look for in resident files, and procedures to follow if the facility is not in compliance. When they survey a facility they are provided with a list of the residents in the facility, regardless of payment source, that have received a PASRR assessment and for whom services were recommended. A number of these residents are included in the survey sample. They look to see that the facility has followed up on the recommendations in the Level II by providing or arranging for services for the resident. If the facility has failed to comply with the requirement they can be cited for a deficiency and required to submit a plan of correction. The surveyors also check the audited survey sample files to see if a Level I form is present and, if a Level II is indicated, that the Level II is in the file. The Department of Health is represented at inter-agency/departmental PASRR meetings, which provide oversight of the program and facilitate interagency collaboration. In addition they participate in two PASRR trainings per year that are provided for PASRR evaluators to learn of any program changes and to explain and answer questions about their role in the PASRR process.
3. The State Medicaid Authority contracts with an outside entity to perform level of care (LOC) surveys. These surveyors are provided the same PASRR training that the Department of Health surveyors receive. The surveyors receive a list of Medicaid funded PASRR residents for each facility they are surveying and check to see if the facility has followed up on the Level II recommendations for each resident reviewed. They also check to see if Level I forms have been completed and are present in all resident files, and a Level II if indicated. These surveyors have been extremely helpful in identifying residents who should have received Level II evaluations, but were somehow missed, and residents who should have been referred for a Level II evaluation because of a significant change in condition. Representatives of the organization attend inter-agency/departmental PASRR meetings that foster communication and collaboration. They also participate in the trainings for PASRR evaluators to explain their role in the PASRR process and answer questions.
4. The State contracts with community mental health centers (CMHCs) to perform PASRR MI Level II evaluations. The CMHCs are private not-for-profit agencies and are not operated by the state mental health authority. When the requirement to perform annual PASRR reviews was repealed in 1996 Indiana elected to continue the reviews in a modified way. Each center maintains a record of all individuals for whom they had performed a pre-admission screening Level II and were subsequently admitted to a nursing facility. They perform a follow-up Level II evaluation one year after admission if the individual is still a resident of the facility to determine the progress of the individual and to ensure that the nursing facility is addressing the resident’s needs. If the evaluator is satisfied that the resident is receiving appropriate care the individual will not receive further PASRR evaluations unless the CMHC is notified of a significant change in condition. The follow-up evaluation is not done if after the initial Level II the CMHC has enrolled the resident as a client and has provided, or continues to provide, services to the individual. Much care is taken to eliminate any possible conflict of interest. When the CMHC does the initial PASRR Level II evaluation they are serving as an agent of the state performing an administrative function and the individual is not enrolled as a client. After admission to the nursing facility the CMHC only provides services to the resident when services are requested by the individual, the nursing facility, or other responsible party. Evaluators are instructed not to solicit clients during the PASRR process. This distinction is important, especially in rural areas, because the CMHC may be the only qualified mental health provider in the area. This again relies on the principle that the nursing facility is ultimately responsible for the care of its residents.
Do these processes actually make a difference? While no comprehensive study has been done there is much anecdotal evidence that they do. A few years ago the State Medicaid Authority was changing to a case-mix reimbursement payment system for nursing home care. As part of this effort the SMA contracted with an outside entity to review the files of every nursing home resident in the state and to prepare a report. Over 40,000 files were reviewed. The report found that of the residents who had received a Level II evaluation, were determined to have a mental illness and/or ID/DD, and to require services for their disorder, eighty-seven percent (87%) had received services for their condition. Unfortunately it was beyond the scope of this study to determine the appropriateness and quality of the services provided and the outcomes for the residents. With the rapidly growing older adult population and the increased life span of persons with serious mental illnesses and ID/DD disorders, this is an area where more research is desperately needed.
Download the PDF below to access contact information for the key informant from the state, Willard Mays.