1. Do I Need a “Bock”? Pre-Admission Screening Resident Review (PASRR) Elizabeth Damers, LPC, LSW Director of Case Management Medical Center of South Arkansas

2. Objectives  Describe the purpose and criteria for a PASRR level I review  Identify patients who are and are not PASRR clients  Understand how to complete a PASRR level I application  Discuss how to request a hospital discharge exemption

3. What is the purpose of a PASRR Level I screening?  To confirm if a person has severe Mental Illness (MH), Intellectual Disability (ID), or a Developmental Disability (DD).  Prevent admission of persons with MH, ID, or DD to a nursing home if there is a less restrictive option.  Determine if a Level II review is necessary.

4. Criteria: Who needs a PASRR Level I screening?  A PASRR Level I must be completed and submitted to Bock Associates for any person with a diagnosis of serious MH, ID, DD, or is or has recently been homicidal or suicidal (a danger to self or others):  Before admission to a nursing home  Before an identified PASRR client returns to a nursing home after a significant change in behavior resulting in admission to an inpatient psychiatric hospital

5. Identify patients who are and are not PASRR clients - the DMS-787 form  Every person who is a potential nursing home admission should have a 787 completed BEFORE they are admitted to the nursing home.  Red flags that should trigger more digging:  Behaviors  Medications  “Young” persons on disability  Inability to sign their name

6. Mental Retardation/Developmental Disability 1. Does the individual have a diagnosis OR history of Mental Retardation OR a related condition?  Mental Retardation  Cerebral Palsy  Autism  Epilepsy/Seizure  Other (Traumatic Brain Injury, Spina Bifida, Down Syndrome)

7. Mental Retardation/Developmental Disability cont.  Did the Mental Retardation develop before the individual reached the age of 18? Yes or No  Did the Developmental Disability (TBI, Seizures) develop before the individual reached the age of 22? Yes or No  If the TBI or Seizures began after the age of 22 (stroke, MVA, etc) be sure to mark No and add a note (“post stroke at 57y/o”)  Digging:  Did he/she go to a special school? Attend special classes?  Has he/she ever attended a “workshop” to go to work?  Has he/she ever attended insert the name of your local DDS program?  Did he/she have seizures when he/she was a child/in school?

8. Mental Retardation/Developmental Disability cont. 2. Has the individual received services from an agency that serves persons with MR/DD? Yes or No  Digging: use names of area group homes, agencies, programs If yes, please provide the name and addresses of this agency. (Include ICF/MR)  Hint: if they don’t know the exact name, write down what they know and the name of the city/state.

9. Mental Retardation/Developmental Disability cont. 3. Is there presenting evident (cognitive or behavioral) that may indicate the presence of MR/DD? Yes or No A. If yes, does the condition result in substantial functional limitations in three or more of the following areas of major life activity? Yes or No Self CareMobilityIndependent LivingLanguageSelf-Direction Learning Hint: ask in simple terms (i.e. can he/she stay home alone; does he/she drive; can he/she shop alone; does he/she need help with bathing, dressing)

10. Mental Retardation/Developmental Disability cont. 4. Does the individual’s behavior or recent history indicate s/he is a danger to self (suicidal or self-injurious) or others (combative)? Yes or No If yes, comment

11. Mental Illness 1. Does the individual have a diagnosis or history of mental illness? Yes or No SchizophreniaSchizoaffectiveDelusional (Paranoid) SomatoformPsychosisMajor DepressionBi-Polar D/O Panic or AnxietyOther (PTSD, Personality Disorder, etc.)  Digging:  Have you ever seen a doctor at (use the name of your community MH center)  Have you ever been in the hospital for depression or your nerves?  Have you ever taken medicine for your nerves or depression?  Have you ever been to the State Hospital?

12. Mental Illness cont. 2. Has the individual been prescribed any psychotropic medications on a regular basis in the absence of a confirmed mental disorder? Yes or No If yes, please list medications (and why) Amitriptyline-insomnia Ativan-anxiety caused by oxygen hunger Remeron-loss of appetite due to ______ Celexa-chronic pain Ritalin-narcolepsy Zyprexa-behavioral manifestations of Alzheimer’s

13. Mental Illness cont. 3. Is there any presenting evidence of disturbance in the orientation, affect, mood, or behavior that suggests mental illness? Yes or No  Hint: this is a question to trigger you to observe and consider the person’s affect, mood, or behavior.

14. Mental Illness cont. 4. Has the individual received treatment within the last two years by any of the following caregivers? Yes or No Mental HospitalHospital Psych Unit  Digging  Has he/she been in a hospital to have his/her Dementia diagnosed?  Have you ever been in the hospital for your nerves or depression?

15. Mental Illness cont. 5. List the name and address of any individual or agency providing diagnosis of treatment for MI. Important, please list.  Hint: use this area to give information. Give dates if available.  If the person has a MH diagnosis, when/where did they receive it?  First and last Inpatient psychiatric hospitalization  Who is treating them (Community MH Center, private psychiatrist)  Did their PCP start the medication?  Why did they start taking the medication? (illness, loss, loss of independence)  Ever seen a Psychiatrist for Inpatient treatment? Outpatient treatment?

16. Mental Illness cont.  Helpful statements:  PCP began ____ for symptoms of depression related to ____ (death of spouse, decreased socialization due to health, loss of independence, spouses health problems, financial stress, family stress, etc)  No history of Inpatient care by a psychiatrist  No history of Outpatient care by a psychiatrist  PCP now manages meds with good symptoms control

17. Mental Illness cont. 6. Does the individual’s behavior or recent history indicate s/he is a danger to self (suicidal or self-injurious) or others (combative)? Yes or No If yes, comment (Yes, the same question again)

18. Mental Illness cont. 7. Is there a diagnosis of Dementia, OBS, Alzheimer’s or any related organic disorders. If yes, complete DMS-780 form. Yes or No Section III Only a person with POA or Guardianship can sign the forms for the patient. The patient can sign with a mark or initials if he/she is having difficulty signing their whole name and staff can sign as witness. If the patient is “unable to sign” write an explanation of why (paralysis or some other physical condition that prevents them from holding a pen). Two persons should witness.

19. Dementia Diagnosis Substantiation DMS-780 Dementia as a stand alone diagnosis IS NOT criteria for a PASRR Level I screening unless he/she is considered to be suicidal or homicidal. Psychotropic medications prescribed to treat the behavioral manifestations of Dementia are not a stand alone criteria for a PASRR Level I screening If the patient has had a recent admission to a geropsych unit, they may need a PASRR Level I screening (if they were admitted because they were a danger to themselves or others)

20. Dementia Diagnosis Substantiation DMS-780 cont. Section I  Dementia Diagnosis: Alzheimer’s, Dementia due to Alcohol, etc  The diagnosis was made on the basis of: (check all that apply)  Discuss the behavior, history or physical findings that lead to the Dementia diagnosis: confusion, disorientation, wandering, loss of ability to perform ADL’s, loss of communication skills, etc  When was the diagnosis of Dementia first made? (Approximate date) month and year or just year will suffice

21. Dementia Diagnosis Substantiation DMS-780 cont. Section II  Does the individual’s current behavior indicate that he/she is a danger to self (suicidal or self-injurious) or to others (combative)? Yes or No  Does the individual have a diagnosis, history or other evidence of one of the Serious Mental Illnesses listed below? Yes or No (how did you answer the 787?)  Is Mental Illness the primary diagnosis? Yes or No  Did the Mental Illness exist prior to the onset of Dementia? Yes or No

22. Nursing Home Admission Criteria DHHS-703  To meet nursing home admission criteria, a person must be determined functionally disabled, by a licensed medical professional, in one or more of the following:  Functionally disabled is impairment in one or more of the following:  Activities of daily living  Transferring/Locomotion  Eating  Toileting  Cognitive impairment  Medical Condition

23. Nursing Home Admission Criteria DHHS-703 cont.  Use the 703 to explain why the person needs to be in the nursing home.  List month/date of hospitalizations in the past 6 months  List the Reasons for hospitalization (Diagnosis)  State how much assistance is needed with transfers and ambulation.  If the patient is continent, do they need help with transfers to the commode, help with pericare?  If the patient is incontinent, do they need someone to change their diaper, provide pericare?  If the patient has a foley, do they need someone to empty the foley?

24. Nursing Home Admission Criteria DHHS-703  Explain assistance needed to eat. (Set up is no longer enough assistance)  Give details of dressing changes.  Give details for confusion or needs supervision. (wandering, forgets to eat, needs frequent reorientation)  Other Medical Conditions. List medical problems.  Medication/Treatments: list names of meds and send a MAR  Therapies: If the person is going for SNF, what therapies will they recive?  DME: what DME is the patient using?

25. Nursing Home Admission Criteria DHHS-703  RN/Counselor Comments  What was the patient’s prior level of function? ADL’s, Mobility, Cognitive Function  What caused a change in their level of function? Extended hospitalization, post surgery, post stroke  What is the patient’s care needs? Continued therapy, IV Abx, Monitoring during medication adjustment, nutritional support, wound care  Is family available or able to provide the needed assistance?  Does the patient plan to return home when they regain their prior level of function?

26. Nursing Home Admission Criteria DHHS-703  Status of Major Impairment? Improving Stable Deteriorating  Prognosis  Diagnosis A & B  what medical condition(s) requires nursing home care?  A person CANNNOT go to a nursing home because they have a mental health diagnosis.

27. Exempted Hospital Discharge  A PASRR client can be exempt from a Level II screening prior to admitting to a nursing home IF:  The client is being admitted to a nursing facility after receiving acute inpatient care at a hospital; AND  The client requires nursing facility care for the condition for which s/he received care in the hospital; AND  The attend physician upon signing this document has certified to the nursing facility that the applicant is likely to require less than thirty (30) days of nursing facility services.

28. Exempted Hospital Discharge  If your patient is a PASRR client or you think they may be a PASRR client and they plan to enter the nursing home for <30 days, send a HED form with your PASRR packet. Note on your fax cover sheet that you included the HED form.

29. Submitting a PASRR Level I application  Fax cover sheet with your contact information and fax number  703  787  780 (if appropriate)  HED (if appropriate)  History & Physical  Psychological Evaluation  MAR  Discharge summary from previous hospitalizations  Power of Attorney or Guardianship papers  IQ and Adaptive Behavior testing if the person is ID/DD

30. Determination  You will be notified via fax of the outcome of the review by Bock Associates and OLTC (if a PASRR client)  Bock Associates tries to process all Level I packets received by 3:00pm the same day.  If you think you might not need to send in the PASRR Level I, CALL and talk to Steve or Bliss.

31. Contact Information Bock Associates 221 West 2 nd Street, Suite 607 Little Rock, AR 72201 State Project Director-Bliss Beeman, RN Clinical Associate-Steve Tam, RN Administrative Assistant-Viki DeClerk Phone 501-374-2559 Fax 501-374-2541 bockarkansas@gmail.com Website: bock-associates.com

32. Questions?