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PASRR Provider TrainingApril 2018

4/18/2018

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Morning Agenda

Time Topic

9:00–9:10 AM Introductions

9:10–10:10 AM PASRR Review

10:10–10:25 AM Break

10:25–10:45 AM Document Based Reviews

10:45–11:10 AM Short-Term Approvals

11:10–11:30 AM Discharge Planning

11:30 AM–12:00 PM Q&A

12:00–1:00 PM Break for lunch (on your own)

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Afternoon Agenda

Time Topic

1:00–2:00 PASRR-identified Services and Community Placement Supports

2:00–2:15 Break

2:15–2:45 Ben Mulford —Iowa Dept on Aging: Office of Substitute Decision Maker

2:45–3:15 PathTracker

3:15–4:00 Q&A

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Learning Objectives

1.Describe the purpose and function of PASRR

2. Identify the appropriate use and application of short-term approvals

3.Apply the process and function of discharge planning to short-term approvals

4. Integrate knowledge of Community Placement Supports with PASRR-compliant care plans and discharge planning.

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PASRR Review

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Risks for Persons with Disabilities

R I S K S

• Skill loss

• Increased risk of marginalization:

• Lack of symptom or communication understanding

• Shrinking world/sense of loss/loss of control

• High rates of depression, suicide, “passive suicide”

M I T I G A T I O N

• Educating providers about service/support needs

• Divert/transition

• Ensure admitting facility can meet the individual’s needs

• Demystify the disability

• Build relationships

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Support Needs and Barriers

• Life is a collection of experiences

• Intimacy is sharing those experiences with another

• Persons with PASRR conditions often have barriers experiencing intimacy, leading to increases in:• Loneliness• Earlier mortality• Institutional care

• Discharge planning for persons in PASRR population can present challenges, including:• Need for more community placement supports than others not in PASRR

population• Need for disability specific services located and coordinated in the community• Need for case management services in the community

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Structure & Purpose of PASRR

• Preadmission Screening & Resident Review

• Administered by Centers for Medicare and Medicaid Services (CMS)

– Created in 1987

• Anyone in Medicaid-funded NF screened for:

– Serious Mental Illness (SMI), Intellectual/Developmental Disability (ID/DD), or Related Condition (RC)

• Known or suspected condition = evaluation

– To ensure NF is most appropriate placement

– To ensure receipt of needed services

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Resources

• Many resources available to you

• Quick PASRR review today

• Resources for beginners (and those who want a refresher)

• PASRR 101 presented by PTAC

• Status Change training

• Webinar registration

www. pasrr.com/IowaDefault.aspx

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Optimize an individual’s placement success, treatment success, and

12 © 2 0 1 6 A S C E N D M A N A G E M E N T I N N O V A T I O N S L L C . A L L R IG H T S R E S E R V E D .

How do we reach that goal?

Provide Needed Services

Placement Meets Needs

Identify the Person

(Source: Dan Timmel, CMS, 8-13-2006, 2013)

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Why are PASRR Level I screens for disabilityand Level II evaluations of disability-related needs

important?

• Major diagnosis, not primary dementia• Impairment in major life activities within past

3–6 months, from diagnosis• Recent treatment more intensive than

outpatient more than once within past 2 years or experience of episode of significant life disruption

Mental Illness• Any

psychotropic• Any Anxiolytic • Any

Antidepressant• Any Mental

Health Diagnosis

?Somewhere between MDS triggers & current

national Level II evaluation volumes

----

---B

REA

DTH

OF

SMI D

EFIN

ITIO

N--

----

- Evolving guidance…Evolving guidance…

Serious Mental Illness

1987 1992 1993 2015 MDS Analysis Emerging

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CMS Reform of requirements for LTC Facilities

• Published October 4, 2016 and effective November 28, 2016

• Revision to the requirements that Long-Term Care facilities must meet to participate in Medicare and Medicaid programs

• First comprehensive update since 1991

• Reflects changes and advancements in LTC

• Targeted at “reducing unnecessary hospital readmissions and infections, improving quality of life, and strengthening safety measures for residents”


CMS Reform of requirements for LTC Facilities – 42 CFR 483.20

KEY PASRR UPDATES IN RED:

e)Coordination. A facility must coordinate assessments with the preadmission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes -

– (1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

– (2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

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CMS Reform of requirements for LTC Facilities – 42 CFR 483.20

TRANSLATION:

483.20(e)(1) - Clarifies and strengthens requirement that all PASRR-identified services and supports must be incorporated into the resident’s care plan and active discharge planning

483.20(e)(2) - Clarifies that PASRR coordination also includes compliance with significant change in status reporting requirements, further defined in Chapter 2 of the MDS 3.0 RAI Manual


PASRR Components

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Level I Disability Screen

Level IIIn-Depth

Evaluation

Determination & Notification

Nursing Facility

Other Appropriate Placement

Resident Review Upon Relevant Status Change

Everyone receives a

Level I

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Researching Level I Information

History and Physical (H&P) conducted within the past year*

MAR

MDS

Psych notes/eval*

Physician’s orders

Therapy notes

Discharge summaries

Individual

Legal guardian*

Support providers

Case Manager

Family members


No PASRR condition

• Can admit to NF

• LI may include service identification

Level I Determinations

Negative Screen Refer for Level II

Known/suspected PASRR condition

• Requires onsite Level II

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23,66874%

6,54420%

2,0426%

LEVEL I VOLUMES

Instant Approval

Negative Screen orCategorical/Exemption

Refer for Level II

July 2017 – Feb 2018

32416%

53526%1130

55%

533%

LEVEL II ASSESSMENTS BY OUTCOME = 6% OF TOTAL 32,254

Rehab Only Halted Specialized Services Denied

263

272

Dementia PrimaryNO SMI/IDD

July 2017 – Feb 2018

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Level I Disability Screen

Level IIIn-Depth

Evaluation

Determination & Notification

Nursing Facility

Other Appropriate Placement

Resident Review Upon Relevant Status Change


Make Determination

• Is the setting the most appropriate for this person?

• Is it acute enough?

• Is it too acute?

• Does the person require time‐limited or ongoing services?

• What is the person’s expected rehab period?

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2,519 84%

1475%

32911%

LEVEL II VOLUMES

MIID/RCDual

July 2017–Feb 2018

1.07

5.574.64 4.63

0

2

4

6

8

10

July 2017 - Feb 2018 July 2017 - Feb 2018 July 2017 - Feb 2018 March 2018

All Clinically ReviewedLevel I - Hours

All Level II - Days Level II Hospital - Days All Level II - Days

Federal Timeframe 7-9 Business Days

Turnaround Times

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Go Fast Checklist

Fill out submission correctlyo Biggest issues are:o Incorrect medication dosage/medication not listed

o Incorrect diagnoses—don’t guess based on prescribed medications

o Incorrectly filling out the ID/RC portion When to mark functional limitations

o Submitting incorrect SSNs and DOBs

Submit supporting documents when available

Submit psychiatric evaluation if conducted during hospital stay


Document-Based Reviews

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Swing Beds and PASRR Clarification

• New Medicaid Conditions of Participation have caused confusion

• 42 CFR 482.58(b)(6)

• Federal and Iowa PASRR policy re: Swing Beds has not changed

• No PASRR needed for Swing Bed Placement

• Swing Bed responsible for incorporating PASRR-identified services if a Level II completed prior to Swing Bed admission


Document-Based Reviews


MAR

MDS

Psych notes/eval*

Physician’s orders

Therapy notes

Discharge summaries

Individual

Legal guardian*

Support providers

Case Manager

Family members

Teamwork

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Break


Time-Limited Determinations

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Categoricals and Exemptions

• Exempted Hospital Discharge (30 days)

• Convalescent Care (60 days)

• Terminal Illness (6 months)

• Provisional Emergency (7 days)

• Provisional Delirium (7 days)

Resources available on PASRR.com


Exempted Hospital Discharge30 Day approval• Discharge from Hospital to NF only• Going to NF for continued treatment for condition treated in hospital• Will discharge within 30 days from admission

Required DocumentationHistory and Physical (H&P) conducted within the past year*Physician’s orders certifying <30 day

If NF required longer than 30 days, a new screen is required

Failure to qualify for EHD does not mean the person can’t go to the NF• Means the outcome isn’t applicable

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Exempted Hospital Discharge: Review

• If a person is in the hospital with pneumonia and requires a couple weeks of NF for PT/strengthening. Are they be eligible for the EHD?

• Yes: in a medical unit, discharging to NF for treatment of same, less than 30 days

• If a person is in the hospital following a hip fracture and requires 3 months of non-weight bearing status. Are they eligible for the EHD?

• No: longer than 30 days

• If a person is in the community and goes to the ED with a broken arm after a fall, are they eligible for EHD? The family says the person can come live at home after some modifications, which will take about 15 days to complete.

• No: Not coming from a medical unit


Convalescent Care60 Day approval• Discharge from Hospital to NF only• Going to NF for continued treatment for condition treated in hospital• Will discharge within 60 days from admission

Required DocumentationHistory and Physical (H&P) conducted within the past year*Physician’s orders certifying <60 day

If NF required longer than 60 days, a new screen is required

Failure to qualify for Convalescent Care does not mean the person can’t go to the NF• Means the outcome isn’t applicable

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Terminal Illness

6-month Approval

• End-stage terminal condition

Required Documentation


Physician’s orders certifying <6 month life expectancy

If the person lives longer than 6 months, a new screen is required

May not be appropriate if the person will continue to benefit from specialized services to address behavioral health issues


Emergency and Delirium

7-day Approval

• Designed for rapid admission to NF

• Only enough time to complete the Level II post-admission

Required DocumentationEmergency: Documentation supporting emergent condition/situationDelirium: History and Physical (H&P) supporting delirium

Emergency• Natural disaster• Caregiver death/unplanned emergent

health issue• Identified caregiver abuse

Delirium• Opportunity to clarify if infection or

PASRR condition is the cause of behavioral health symptoms

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Other Short-Term Outcomes

• Not an identified categorical or exemption outcome

• 30-180 days

• Dependent on individual’s clinical presentation

• Will require Level II completion prior to admission or at the conclusion of previously approved time limited stay

• Discharge planning begins immediately at admission


Summary of Findings and Services/Supports

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Summary of Findings

• Report of PASRR-identified services

• Specialized Services, Rehab Services, & Community Placement Supports

Must:

• Remain in active chart

• Be a clinically accurate representation of the individual

• Be captured in the plan of care

Summary of Findings—PASRR-Identified Services & Supports

Service or Support Rationale for Service or Support

Ongoing psychiatric services by a psychiatrist or a psychiatric Advanced Registered Nurse Practitioner (ARNP) to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders and to evaluate ongoing need for additional behavioral health services.

He will benefit from continuing to receive medication management by his psychiatrist so the continued effectiveness of the medications can be monitored by the psychiatrist. Mr. Jefferson's psychiatrist should remain an active part of Mr. Jefferson's treatment team through participation in case consultations and treatment team meetings.

PASRR-Identified Specialized Services

©2017 ASCEND MANAGEMENT INNOVATIONS LLC. ALL RIGHTS RESERVED

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Summary of Findings—PASRR-Identified Services & Supports cont.

PASRR-Identified Rehab Services


PASRR-Identified Community Placement Supports

Summary of Findings—PASRR-Identified Services & Supports cont.

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Discharge Planning


Light Blue = at least one person/zip code

Orange = 170 persons/zip code

Metropolitan areas have several zip codes with 170 or more persons

Location of Persons with Level II Determinations, by Zip Code

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Location of Persons with Level II and Specialized Services Identified

Light Blue = 1.59 persons/zip code

Orange = 15.9 persons/zip code


Location of Persons with NFMI LOC, by Zip Code

Light Blue = 1

Orange = 49

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Discharge Planning—Hospitals

Begins at admission

• Avoid delays

• Ensures timely completion of Level II when needed

• Provides opportunity for NF to ensure they can meet person’s needs

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Discharge Planning—NF

Begins before admission

• Review of Pre-Admission PASRR

• Is this person in PASRR population?

• Can you deliver all PASRR Identified Services?

• Does it appear the individual will participate in PASRR Identified Services?

• How will NF team help the individual reach the goal of achieving successful treatment and discharge within the specified timeframe?



After Admission

The NF must incorporate ALL PASRR-identified services

• Care Plan Must Include (within 21 days)

• Start Date of each service

• Name and Credentials of Provider

• Expected Frequency

• Anticipated Duration

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Discharge Plan vs. Active Discharge Planning

Active Discharge Planning

Engage the person to identify

personal goals

Form discharge plan

Incorporate PASRR

Identified Services in to

care plan Coordinate Community Placement Supports

Discharge the person to a safe and supported

community placement

© 2 0 1 5 A s c e n d M a n a g e m e n t I n n o v a t i o n s L L C . A l l r i g h t s r e s e r v e d . 68

The US Supreme Cour t Olmstead Decision

June 22, 1999

Photo courtesy Jeffrey Macmillan for US News &World Report

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The Olmstead Decision

Unjustified segregation constitutes discrimination

Public entities must provide community-based services when: – Appropriate

– Persons do not oppose community-based treatment

– Community-based services can be reasonably accommodated



Include Community Placement Supports—plan for timely discharge

• When the individual has a short term approval

• When the MDS Section Q500 indicates the person wishes to discharge

• The individual communicates a desire for discharge

• Yes we’re serious

• If the individual has expressed a desire to return to the community

• Even if we think it is not realistic

• Consider if a new PASRR is needed

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Short Term Approval and Discharge Planning

• Time is of the essence

• Don’t expect that another short term PASRR will definitely be approved

• This could be the last approved PASRR

• Be creative in where you might locate a service identified as Community Placement Support

• Volunteers

• Paid Supports

• Community groups

• Family/friends

• Religious organizations


When to Care Plan and Tips on When to Begin Discharge Planning:

Iowa Care Planning Tools available on the website: www.PASRR.com/Iowa

• Provider Tools Section• Summary of Changes to Iowa Care Planning Tool: Specialized and

Rehabilitative Services

• Updated Iowa PASRR NF Level II Care Plan Tool

• View the 13 minute video:• Care Planning Tool—How To Video 01.30.2017

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Critical Elements of PASRR Compliant Care Plans

• Care plan developed no less than 21 days from admission to NF

• If PASRR indicates specialized services and a short term approval

• ServiceMatters review issued on day 21 for any approvals with 60 days or less

• ServiceMatters review issued on day 30 for any approvals for 61–180 days

• If PASRR indicates specialized services with a non-time limited approval

• ServiceMatters review issued on day 45

• If MDS section Q500 indicates person wants to return to community

• NF must include Community Placement Supports in care plan and Service Matters review

Don’t assume another PASRR approval will be granted for a person with a short-term approval

Questions?

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Lunch


Afternoon Agenda

Time Topic

1:00–2:00 PASRR-identified Services and Community Placement Supports

2:00–2:15 Break

2:15–2:45 Ben Mulford—Iowa Dept on Aging: Office of Substitute Decision Maker

2:45–3:15 PathTracker

3:15–4:00 Q&A

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PASRR-Identified Services


Definitions

• Rehabilitative Services= typically essential available in nursing facilities, PT, OT, speech, dental care, etc. to promote positive health outcomes

• Specialized Services = unique to the person; meet specific disability needs

• Community Placement Supports = unique to the person; assist with optimal independence and transition to community-based living

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Common PASRR Rehab Services

• ADL training

• Community living skills training by the nursing facility or other provider.

• Assistive devices or technology

• Assessment for needs or specify type

• Self-health care management training

• Education regarding medicine compliance and/or side effects

• OT/PT therapy/evaluation

• Speech/language therapy This is not an exhaustive list. For the complete list, refer to PASRR.com and

in your supplementary materials


Specialized Services

• Acute Inpatient Psychiatric Treatment

• Initial Psychiatric Evaluation to determine diagnosis & develop care plan

• Ongoing psychiatric services by a Psychiatrist or Psychiatric ARNP to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services

• Individual Therapy by a licensed behavioral health professional (may include Mobile Therapy)

• Group Therapy by a licensed behavioral health professional

• Neuropsychiatric evaluation by a neurological and behavioral health professional

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• Psychological Testing for differential diagnosis, resulting in appropriate treatment plan revisions and services

• A functional assessment of maladaptive behaviors by a behavior analyst or qualified behavioral health professional with equivalent experience

• A behaviorally-based treatment plan to include both routine and crisis related behavioral supports developed with assistance from a behavior analyst or qualified behavioral health professional with equivalent experience



• Development, by the individual, of a Behavioral Health Advanced Directive (such as a Wellness Recovery Action Plan, WRAP), with support and assistance from a Certified Mental Health Peer Support Specialist or other appropriately trained behavioral health professional

• Peer Support Services, delivered by a Certified Mental Health Peer Support Specialist

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Community Placement Supports—5 Categories

• Environmental Management

• Access to Community Resources • Including transportation

• Shopping

• Meal Preparation

• Behavioral Health Supports

• Community placement– With or without supports

• Independent living

• Group home

• Assisted living

• Person directed care

Might this person be a candidate for transition to the community?

What supports or services would be necessary to return to the community?

Might this person be a candidate for transition to the community?

What supports or services would be necessary to return to the community?

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The Power of Hope

• PASRR goal = optimize the individuals placement success, treatment success, and quality of life

• Start with the premise that everyone receiving a Level II PASRR evaluation has the potential to return to the community following a successful nursing facility stay.

• Never know what changes may happen after PASRR completion

• Community Placement Supports always identified

• A true measure of success is when a nursing facility helps a person return to the community.

• Community Placement Supports are an essential part of optimizing the lives of individuals and helping them succeed


Environmental Management

Cleaning Supports: maintaining the cleanliness of the home interior

Lawn Care: maintaining the individual’s home exterior, including mowing grass, trimming bushes, weeding and watering, raking leaves, and snow/ice removal

Home Health Aide: paid staff to assist in the home with ADLs

Home Health Nurse: nurse who assists in the home with administering medications and specified medical supports, as ordered by a physician

Outpatient or in-home OT/PT/SLP: Therapy services provided in the home, as ordered by a physician

Hospice Services: Services that focus on the palliation of pain/symptoms for a person with chronic illness, terminal illness, or serious illness, and attending to their needs

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Environmental Management, cont.

Medical Alert systems or devices: alarm system designed to signal the presence of an urgent need and summon emergency medical personnel

• Also known as: Personal Emergency Response System (PERS) or medical alert

Assessment for Payee or Other Financial Assistance: Assist with managing financial affairs.

• Typically involves a Representative Payee for management of Social Security benefits

Guardian/Conservator/Power of Attorney for Healthcare to Assist with Decision-Making Health and Safety: Secure a legal guardian, conservator, or power of attorney to assist with making decisions regarding health and safety

• Court must appoint and approve guardianship/conservatorship

• The Power of Attorney does not require the court for involvement



Referral to Office of Substitute Decision Maker, Department on Aging: assistance with making major life decisions

• Contact the Department on Aging to assist with coordination

Development of Healthcare Advanced Directives: legal document, such as a living will, to provide guidance for medical and health-care decisions, such as the termination of life support or organ donation, in the event the person becomes incompetent to make such decisions

Referral for a Medical Home, Healthcare Coordination for Individuals with Complex Health Need: person receives medical supports in a specified medical home that offers healthcare coordination to assist with managing complex health needs

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Referral for Integrated Health Home (IHH): team approach for coordination of health and behavioral health services for an individual with SMI and complex needs

• Includes a Certified Mental Health Peer Support Specialist

Other services available under Iowa Medicaid:

• Program of All-Inclusive Care for Older Adults (PACE)

• Home Health

• Habilitation

• MH Peer Support

• Hospice

• Targeted Case Management (TCM)

• Money Follows the Person (MFP)



Referral for Eligibility Determination for Medicaid Coverage, Including HCBS Waivers: Medicaid programs offering choices about how and where you receive services

• For people with disabilities and older Iowans

• Can stay in home and community instead of institution

• Seven HCBS Waivers:

• Physical Disabilities

• Health and Disability

• Elderly

• Intellectual Disabilities

• AIDS/HIV

• Brain Injury

• Children’s Mental Health

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Shopping

Home Care Aide: Paid person to assist in the home with completing shopping

Family, Friends and Other: NF coordinating with the person’s family, friends, or other entities who will assist with shopping

Assistive Devices or Technology: Technology to assist with dressing, hygiene, ambulation, communication, and other functions

• Can include devices for reaching/grasping objects


Meal Preparation

Meals on Wheels: Delivers prepared meals to those who are unable to purchase or prepare meals

• Name used generically to refer to home-delivered meals programs

Assistive Devices or Technology: Technology to assist with safe eating

• Includes modified utensils, plates, blenders, food processors, etc.

Family, Friends, Others: Nursing facility coordination with family, friends, or others who will assist with meal preparation

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Access to Community Resources, Including Transportation

Public Transportation/Bus Pass: Securing a bus pass or access to public transportation

Supported Public Transportation: Transportation to shopping and medical appointments

Arranged Public Transportation/Taxi Service: Coordination of taxi services

• Funding sources can include private funds, Medicaid, and private insurance

Respite Services for Caregivers: Paid caregiver to allow the individual’s caregiver to receive a needed respite.

Assistive Devices and Technology: Devices to assist with mobility

• Can include ramps, wheelchairs, walkers, canes, etc.


Behavioral Health Supports & Services

Individual Therapy by a Licensed Behavioral Health Professional (may include mobile therapy): Counseling and therapy by a Licensed Behavioral Health Professional

• Must be a licensed Behavioral Health Professional

Psychiatric Services by a Psychiatrist to Evaluate Response to Psychotropic Medications, Modify Medication Orders and to Evaluate Ongoing Need for Additional Behavioral Health Services: Securing Psychiatrist or ANRP who specializes in psychiatry while in the nursing facility and coordinated for community services prior to NF discharge

• Services should be delivered with continuity of care as a foremost consideration

Partial Hospitalization/Day Treatment: Ongoing intensive behavioral therapy and access a variety of Behavioral Health professionals

Group Therapy by a Licensed Behavioral Health Professional: Counseling sessions in a group setting led by a Licensed Behavioral Health Professional

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Behavioral Health Supports

Peer Support Services, delivered by a Certified Mental Health Peer Support Specialist: Delivered by an individual with SMI, in recovery, who has completed Peer Support training and become certified in Iowa.

• Distinct service where the professional providing the service must be a certified MH Peer Support Specialist

Referral for Integrated Health Home (IHH), healthcare coordination for individuals with serious mental illness (SMI): offers a team approach to address the needs of community dwelling individuals with high behavioral health needs, includes:

• Psychiatry

• Nursing

• Certified Peer Support Specialist


Behavioral Health Supports

Referral to a Community Based Recovery Center: assist an individual with SMI who seeks to enter recovery and remain strong and stable in their recovery. Services may be free and available to those who also reside in residential settings

Case Management for Frail Elders: Case Management designed for older adults (64+) for any type of Behavioral Health services and supports that may need to be arranged and managed while residing in the community

• Not a Medicaid service

• Available through AAA

Initial Substance Use Evaluation to Determine Diagnosis and Develop a Plan of Care: Evaluation to determine substance use diagnosis

• Identify a course of inpatient or outpatient treatment

• Development of care plan that can include other behavioral health services

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Behavioral Health Supports, cont.

Referral for Outpatient Substance Use Treatment: Supports with services for addiction to various substances in an outpatient setting

• Sought prior to discharge

A support group for recovery from substance use (AA, NA, etc.): Local recovery group such as AA, NA, Celebrate Recovery, etc. These groups are private and are developed by other individuals in recovery, often in churches or other community settings, including nursing facilities

Other support group(s): PASRR will specify the area for the needed support group


When to Care Plan and Tips on When to Begin Discharge Planning

• Care plan developed for each person no less than 21 days from admission to NF

• ServiceMatters review will be issued if specialized services identified:

• Day 21 for any approvals with 60 days or less

• Day 30 for any approvals for 61 to 180 days

• Day 45 for any non-time limited approval

• If the individual indicated on the MDS section Q500 that they wish to return to the community, must include services in care plan and ServiceMatters review

• Don’t assume another PASRR approval will be given for an individual with a current short-term approval

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Break


Ben Mulford—Iowa Dept on Aging: Office of Substitute Decision Maker

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Iowa’s Office of Substitute Decision Maker/Public Guardian

Working Today to Help Tomorrow

Current Setup

102

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Splits in Decision-Making

▰Voluntary – Powers of Attorney, Joint Accounts, Bill Payer Services▰Involuntary – Family Consent, Guardianships & Conservatorships*▰Ward – Guardianship, Healthcare POA (Principal)▰Assets – Conservatorship, Financial POA* Can be voluntary as well

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“ In the way it treats mentally disabled persons, society has come full circle from the medieval concept of complete control to the humane modern use of the least restrictive alternative.

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Matter of Guardianship of Hedin, 528 N.W.2d 567, 582 (Iowa 1995)

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Personal Care Discussions

▰ Self-direction is ideal scenario▰ Informal community and service involvement▰ Lesser restrictive means of providing care▰ Involuntary Decision-Making

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Powers of Attorney

▰A written legal document in which a person gives another the authority to act for the person▰Principal – Person giving another the power to act▰Agent (Attorney in Fact) – Person who has the authority to act

106

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Executing the Document

▰ Principal must be an adult, have capacity, and it must be voluntary

▰ Document must be in writing (handwritten, typed, form)▻ Name of attorney-in-fact (agent)▻ Responsibilities and authorities granted▻ Signature and date by principal (voluntary adult w/ capacity)▻ Notary or two witnesses

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Powers of Attorney

▰ No Reporting Requirements

▰ Co-Agents

▰ Springing vs. Immediate*

▰ General vs. Specific

▰ Nomination of conservator or guardian

▰ Durability*Immediate not available for Durable Health Care POA

108

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Advanced DirectivesEnd of Life Decisions

▰Living Will (144A.3)▰Out Of Hospital Do Not Resuscitate (OOH-DNR, 641 IAC 142)▰Iowa Physician Orders for Scope of Treatment (POST, 641 IAC 145)▰Family Consent (144A.7)

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Consent Hierarchy (End of Life)

▰Durable, Healthcare POA▰Guardian (w/ court consent)▰Spouse▰Adult Child(ren)▰Parent(s)▰Sibling(s)

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Health Care Power of Attorney

Durable POA for Health care (144B):

Document authorizing an attorney-in-fact to make healthcare decisions for the principal if the principal is unable, in the judgment of the attending physician, to make healthcare decisions.

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“A durable power of attorney for health care may be revoked

at any time and in any manner by which the principal is able to communicate the intent to revoke, without regard to mental or physical condition. … Revocation may also be made by notifying a health care provider orally or in writing while that provider is engaged in providing health care to the principal. A revocation is only effective as to a health care provider upon its communication to the provider by the principal or by another to whom the principal has communicated revocation.

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Iowa Code § 144B.8

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Guardianship

▰ Court Authorized relationship whereby one person assumes the responsibility for the physical custody of another

▰ In the case of a minor, it is person who is not the parent of the minor child, appointed by court to make important life decisions that have permanent effect on the life and development of that child. (Iowa Code 600A)

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Guardianship Standard for the Ward

▰ Is a person whose decision-making capacity is so impaired that the person is unable to care for the person’s personal safety or to attend to provide for necessities for the person, such as food, shelter, clothing, or medical care, without which physical injury or illness might occur.

▰ Is a minor.

114

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What does a Guardian do?

▰Perform duties outlined by court▰Provide for care, comfort, and maintenance of the ward▰Establish place of residence*▰Take care of ward’s personal property▰Consent to medical/professional care*▰File reports**

115* Must have court approval in certain cases** Normally required, but can be removed by court

Powers of a Guardian: Require Court Approval

▰ Changing the ward’s permanent residence if new residence is more restrictive of the ward’s liberties

▰ Arranging for major elective surgery or any other non-emergency major medical procedure

▰ Consent to the withholding or withdrawal of life sustaining procedures (DNR)*

*Durable Healthcare POA outranks Guardian in End of Life Decisions

116

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Termination of Guardianship

▰ Age of majority (if minor guardianship)

▰ Death

▰ Decision-making capacity is no longer impaired

▰ No longer necessary for any other reason

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Finances (Asset Planning)

Self-DirectedMoney Management▰ Bill payer services▰ Representative Payee▰ Joint AccountsTrustsPOA

118

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Conservatorship

▰ Court-authorized relationship in which one person, the conservator, assumes the responsibility for the custody and control of the property of another person, the ward.

119

Conservatorship: Standard

▰ Decision making capacity is so impaired that the person is unable to make, communicate, or carry out important decisions concerning the person’s financial affairs.

▰ Is a minor.

120

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Conservatorship: Types

▰ General or Full

▰ Limited

▰ Temporary

▰ Standby

121

Establishing Conservatorship

▰ Does the proposed ward meet the standard?▰ Consider any and all less restrictive alternatives▰ Voluntary v. Involuntary▰ Timeline:

▻ File petition▻ Notice▻ Hearing▻ Appointment▻ Reports 122

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Powers of Conservatorship:Requires Court Approval

▰ Investing the funds of the ward▰ To make payments to or for the benefit of the ward in the

following ways:▻ Directly to the ward▻ Maintenance, welfare and education of the ward▻ To the legal guardian ▻ To anyone who has custody and care of ward

▰ To apply any income or assets for the support of any person –even if ward is legally liable for support

▰ To sign leases123

Termination

▰ Age of majority (if minor conservatorship)

▰ Death

▰ Decision making capacity is no longer impaired

▰ No longer necessary for any other reason 124

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Iowa: Fields of Opportunity

▰In 2016 an estimated 514,000 Iowans were 65+, Over 16% of the state population▰Average income for this group was over $70,000/yr▰65+ farms averaged $322,512 in annual receipts (15,436 farms)

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Exploitation, Fraud, Trust Abuse

True Link Report on Elder Financial Abuse▰$36.48 billion▻46.6% Exploitation ($16.9b)▻35.1% Fraud ($12.8b)▻18.3% Trust Abuse ($6.6b)▰If there is evidence of $20 per year in petty exploitation it is an indicator of $2,000 per year in other types of fraudHttps://truelink-wordpress-assets.s3.amazonaws.com/wp-content/uploads/True-Link-Report-On-Elder-Financial-Abuse-012815.pdf

126

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PASRR-Identified Services Example

▰Life Long Links – www.lifelonglinks.org 866-468-7887

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Contact

Brian MajeskiAdministrator, Office of Substitute Decision Maker/Public [email protected] | (515) 240-8264

Ben MulfordElder Abuse Prevention Program, Legal Assistance Development,Backup to [email protected] (515) 238-1241

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System Access and PathTracker


Web System Access—www.PASRR.com

• Register for access as Web Supervisor

– Responsible for facility/agency user registration, management, and monitoring

– Submit letter to Ascend on facility/agency letterhead from an authorized officer of the facility, include for staff person:• Name

• Title

• Phone (with extension)

• Fax

Attestation: I affirm that I am authorized to grant approval for access to protected facility information. I affirm that the following individuals have been granted permission by this facility to act in the role of the WEBSTARS™ Supervisor for the purposes of monitoring and managing facility-wide user permissions to access the WEBSTARS™ system.

• Email

• Facility Medicaid Provider ID

• Does your facility have a psychiatric unit? (Yes/No)

• Does your facility have both NF and hospital beds? (Yes/No)

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Process

• Receive an email with your username and temporary password and a link to activate your account

• To the email address you provided

• Web Supervisors may ONLY enroll facility/agency users they supervise

• Responsible for updating their facility/agency users

After approval, web supervisors can:

• Step 1: Log onto www.pasrr.com.

• Step 2: Locate the link on the right labeled Iowa PASRR and click the link to enter.

• Step 3: Click the Supervisor Login icon under the Supervisor Tools section.

• Step 4: Enter your user name and password.

PathTracker Plus (Overview)

Print PASRR outcomes/forms for resident charts

Links to Payment—began 2/1/2016

Submit Status Change Level I screen

Admissions, Discharges, Transfers

Enhanced access to PASRR records

Print PASRR outcomes/forms for resident charts

Links to Payment—began 2/1/2016

Submit Status Change Level I screen

Admissions, Discharges, Transfers

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PathTracker Plus Training is available!

• Iowa PASRR Providers Website: http://www.pasrr.com/IowaDefault.aspx

• Register for Webinars on website, PathTracker Plus training is repeated frequently

• Under Educational Tools:

– ServiceMatters and PathTracker Plus System User Guide


No More Paper CAR Forms—Really!

• PathTracker Plus became available 2/1/2015

• Use became mandatory for all NFs 2/1/2016

• Training was offered many times at implementation via webinar

• PathTracker training continues to be offered regularly

• Ascend and DHS/IME work diligently to resolve issues that have resulted in requests for paper CARs

• There should rarely, if ever, be a need to send a paper CAR form

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Purpose of PathTracker

NF Submits Admission Notice to PathTracker

PathTracker Notifies IME of Admission for Billing Start

IME Processes Billing

PathTracker Notifies IME of Discharge for Billing Stop

IME Processes Billing to Stop

Payment

New NF, If Applicable, Submits

Admission Notice

Provider Submits Notice to

PathTracker

Provider Receives Payment


PathTracker Plus Messages from the Centralized Facilities Eligibility Unit (CFEU)

• Always Use the Correct Admission Date

• Only enter Admission/Discharge notices for actual residents

– If you don’t admit the person, don’t submit an admission notice

• Use your accurate provider/NPI numbers

• No Discharge notice needed if the person goes to the hospital for less than 10 days

• IME & CFEU want to know that EVERY NF has a contact person for PathTracker Plus

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Available in your Resources

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What NF Users See at Log-in

What NF Users Can Do

Review people reported as

admitted to NF

Report admissions, discharges,

transfers, and deaths

Print PASRR records for residents

Enter a new Level I screen

Complete ServiceMatters

Reviews

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When to Use PathTracker

• Admissions

• Discharges

• Transfers

• Changes in Level of Care– PACE

– Hospice

– SNF to NF

• Deaths


PathTracker & Hospitalization

Hospitalized for 11 days or more

• Current NF must discharge in PathTracker

• New PASRR required prior to returning to NF re-admission if Status Change would otherwise be required

Hospitalized for 10 days or less and returns to NF, SC criteria not met

• No discharge in PathTracker

• No new PASRR

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NF Queues

Review Queue


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Accepted Queue

Individual Record

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Report New Admission

Admission Notice

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Admission Notice, cont.

Individual Record

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Discharge/Transfer Notice

Discharge/Transfer Notice, cont.

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Add Individual

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Do not accept a resident through the review queue until they are in your

facility

You MUST fill out the admission notice

This STARTS payment

Complete discharge notice when person permanently leaves or hospitalized for

11 days or moreThis STOPS payment


Who Should You Call with Questions

Ascend Iowa Help Desk• System questions, PathTracker, ServiceMatters, Access

DHS & MHDS

• Questions about letters received directly from DHS• Technical Assistance for compliance & care planning

• Assistance in addressing complex needs or locating & implementing services

• Questions about potential non-compliance or recoupment

IME & CFEU• Medicaid Eligibility and Payment issues• If recoupment or nonpayment is happening, you will be notified first, in writing• Questions about recoupment are appropriate only if/when you are notified

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Review

• PASRR quick review

• Document-Based Reviews

• Where to find PASRR-identified services and supports

• Discharge planning

• Community placement supports

• Substitute decision maker

• System access

• PathTracker

https://www.surveymonkey.com/r/IA0418

IA NursesIf you are obtaining contact hours as a nurse through the IBON, you do

not need to print a certificate of attendance. You will receive your certificate in the mail in Summer 2018.

Remember, you MUST sign in AND out at the registration table to obtain CEUs. Failure to do so will prevent certificate award.

No partial contact hours will be given.

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Resources

Iowa PASRR Providers Website:

– http://www.pasrr.com/IowaDefault.aspx

– Information on Specialized Services Resources for PASRR Providers 5/2/16

– Webinar Slides - Behaviorally Based Treatment Plans by Susan Smith (2/23/2016)

– Webinar Slides - Behaviorally Based Treatment Plans & Specialized Services by Susan Smith (3/15/2016)

– Template - Routine and Crisis Behaviorally Based Treatment Plan

PASRR Technical Assistance Center, Excellent PASRR 101 Presentation:

– http://www.pasrrassist.org/events/webinar/pasrr-101


Resources Continued

Iowa PASRR Providers Website:

– http://www.pasrr.com/IowaDefault.aspx

Provider Tools, for Care Planning:

– Care Planning Tool -- How To Video 01.30.2017

– Summary of Changes to Iowa Care Planning Tool: Specialized and Rehabilitative Services

– Updated Iowa PASRR NF Level II Care Plan Tool

Soon to come on IA Website:

– Slides from NAPP Webinar on PASRR collaboration with LTC Ombudsman’s office

– How & When to utilize the Office of Substitute Decision Maker

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PASRR Resources Continued

Iowa Geriatric Education Center: E-News, E-Learning:– https://igec.uiowa.edu/– Free Monthly Geriatric Lecture Series: https://igec.uiowa.edu/gls

National Association of PASRR Professionals: Monthly Webinars, membership based organization for education and advocacy:– http://www.pasrr.org/

PASRR Technical Assistance Center: Monthly Webinars, all archived– http://www.pasrrassist.org/

Tetrick, F. L. (2018, April 10). Discharge Planning and Transitions into the Community. Retrieved April 10, 2018, from http://pasrrassist.org/sites/default/files/attachments/April_2018_PTAC_Webinar_FINAL.pdf

Des Moines AA groups http://www.aadesmoines.org

Questions?

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