In May 2010 Idaho completed the PASRR Self-Assessment tool and recognized an opportunity to improve their PASRR program. Over the last two years, the state pursued a quality improvement strategy that led to a successful revision of their evaluation tools and processes. The goals, process, and outcomes of this initiative are described below.
Quality Improvement Strategy Goals:
- Assist all involved parties (i.e. hospital discharge planners, doctors, nursing facilities and state staff) to recognize the needs of the individual versus viewing PASRR as just another “paper pushing process”
- Update PASRR process chapter in the Bureau of Long Term Care’s Operations Manual
- Update current forms to assure minimum federal criteria is met and make them easier to understand
- Streamline forms to reduce redundancy
- Work with state authorities (MH and DD) to improve process
- Develop training
- Re-educate discharge planners regarding dementia/Alzheimer’s and the correct referral of individuals with these conditions
Process for Updating PASRR Policies and Tools:
The PASRR Self-Assessment tool was the jumping off point for Idaho’s quality improvement strategy. Completing the self-assessment in May 2010 helped the state determine what it was currently doing correctly and what areas needed improvement. Idaho recognized that the current PASRR forms were not being completed correctly, in part due to the way the questions were worded. This was especially evident in sections relevant to dementia/Alzheimer’s; hospital and discharge planners were using signs of dementia to “short-circuit” PASRR. The state saw this as an opportunity to review and update their entire PASRR process. The state also capitalized on an opportunity to provide education to hospitals, physicians, nursing facilities and other agencies on the PASRR process to ensure smooth transition and proper placement decisions for those involved. Finally, the state sought to make the process more meaningful while easing the administrative burden on the agencies involved. Idaho created an Action Plan to organize the initiative.
Developing clear and understandable forms was a priority for the state. Rather than reinvent the wheel Idaho researched and leveraged existing materials from other states. The state did an overall review of ten states and an in-depth review of Texas, North Carolina, Colorado, and South Dakota. Ultimately, the state used forms from North Carolina and Colorado as models for their redesign since these states’ forms were appropriately detailed and logically organized.
Between June and September of 2011, Idaho undertook multiple revisions to their Level I screen, both of their Level II evaluation tools (MH and DD), and their nursing facility level of care determination. Findings included in the Idaho State Fact Sheet, an addendum to PTAC’s National Review of State PASRR Policies and Procedures, helped inform the changes the state chose to make to their forms. To achieve buy-in from their community partners, the state chose to pilot the revised forms with two hospitals from October through December 2011. The hospitals provided valuable feedback after the pilot period and the forms were revised again thereafter.
Idaho developed a PowerPoint Presentation that was used for several webinar trainings in early 2012. Between February and March 2012, Idaho Medicaid held six webinar trainings for hospital discharge planners, physicians, and nursing facilities. This training was also presented to the Idaho Health Care Association at their summer workshop and Idaho state staff were trained via video conference. An online training was developed and posted to the Medicaid website for community partners who were unable to attend the webinars.
Statewide implementation of the updated process and forms began April 1, 2012. Nursing facilities have refocused their efforts to make the state mental health and developmental disability authorities more aware of individuals’ status changes. Since implementation, two individuals have been diverted from a nursing facility to a more appropriate placement. Several other individuals are now receiving specialized services or services of a lesser intensity, which has resulted in life improvement.
According to PTAC’s 2012 National Review of State PASRR Policies and Procedures, Idaho’s former policies and procedures were between 51%-75% comprehensive. Through the revision process Idaho added significant detail to their Level II tools, including questions that evaluate individuals’ ability to complete specific activities of daily living and instrumental activities of daily living. The state also developed questions to assess individuals’ propensity to exhibit self-injurious behavior and individuals’ current living arrangements and social support systems. In addition to the evaluation forms, Idaho updated the PASRR process chapter in the Bureau of Long Term Care's Operations Manual, which describes process flow and staff responsibilities. After PTAC’s review of Idaho’s revised policies and procedures, the state is now somewhere between 76%-100% comprehensive.
A Success Story:
ML was born in 1968 and has diagnosed Cerebral Palsy and seizure disorder. He spent much of his early adult life in an ICF/ID and was admitted to a skilled nursing facility due to medical complications in 2000. At that point, he was also diagnosed with a mood disorder. Due to behavioral issues and problems with care, ML regularly moved from one nursing facility to the next; for several years, one nursing facility was actually paid a special rate to care for ML.
As a result of the additional training described above, individuals previously not identified were now being referred for Level II evaluations and resident reviews. ML’s case was reevaluated in 2012 as a resident review. As a result of the resident review, the State DD authority recommended that he be evaluated for the Adult DD/Residential Habilitation waiver as a part of the Level II process. ML met the criteria for their waiver and shortly thereafter was moved from the nursing facility to an apartment that he shares with another client. ML now lives in the same town as his mother. He has been successful in this move and is reportedly very happy.
Below, you can download the revised PASRR process chapter from Idaho’s Bureau of Long Term Care’s Operations Manual. You can also find an Action Plan developed by the state to help guide their reform process. Finally, you can find contact information for the point persons in Idaho should you have any questions for the state.
1 Comprehensiveness scores measured the degree of adherence to regulatory requirements and good clinical practices in states’ Level II MH and DD evaluations.