The following question was asked of the readers of the Journal of Gerontological Nursing:
The Omnibus Budget Reconciliation Act (OBRA '87) required several changes in the Medicare and Medicaid programs for nursing home care. Among the changes mandated by this legislation was screening of all persons prior to admission to a nursing facility targeting the mentally ill, mentally retarded, and those with related conditions such as cerebral palsy and autism, so that they would be appropriately placed in nursing homes that could meet their needs. This was accomplished by mandating Pre-Admission Screening and Annual Resident Reviews (PASARR).
In your opinion, has the PASARR effort been successful for the mentally ill elderly?
No, it hasn't been successful. Inconsistency in reviewers' techniques on annual reviews is the main problem; however, it could be made better. The PASARR is a step in the right direction. The screening itself is good, but the Annual Resident Reviews are problematic.
Helen Sloan, RN, CS, MSN
University of SW Louisiana
No! I have never seen or had knowledge of a potential admission banned because of a GES determination. Likewise, I was never able to place a resident in a psychiatric setting who desperately needed to be placed in one. I think it's just another form to do. I know that these "placement" problems are caused by the lack of adequate psychiatric facilities that can also handle medical problems as well as the lack of payer sources.
Rosanna M. Dellegroth, RN, MSN
Director of Nursing
Fox Chase Nursing and Rehabilitation
Silver Spring Maryland
I do not think the PASARR has been successful. In my rural area, there are no nursing homes with programs for the mentally ill. Screening does not keep the mentally ill out of the nursing home where I work. At the present time, we have two residents in our 87-bed facility who would be much better served on a psychiatric unit.
Mary Ann Christensen, RNC, BAN, PHN
Minnesota Manor Health Care Center
The PASARR is a simple form and is easy to understand if you have access to a person who knows the background of the prospective resident. That is not always possible, and at times the resident also cannot give the data because of physical and/or mental problems. Many of us live in border communities, and residents come from several different states. I question whether everyone would intrepret "mentally retarded or related condition" as cerebral palsy, autism, etc.
In Minnesota, the screening is done by the county social workers, usually by telephone. How can you obtain the most correct answer by talking to a confused 87-year-old who has not been to a doctor for 6 years and has no family around? Someone, occasionally a concerned neighbor, thinks the individual needs care and calls for help. This is in small-community USA, not a big city where no one knows anyone. What about street people? Who can give correct answers for them? They also are in small-town USA, not just cities.
In Illinois, the state hires Lutheran Social Services or some such agency to do this screening. It is not always their forte. Because the screening does not need to be done prior to admission, what use is it then? Most of the time it is done, but by the rules, and there could be problems.
When the screening is done correctly, usually there is no choice regarding the location of the nursing homes. Many communities only have one general purpose nursing home. The goal is to keep people in their communities so they may retain familiar contacts. Most nursing homes do not specialize in problem areas. Usually, there is not sufficient funding to care for these special problem areas.
The screening costs money. Minnesota charges every long-term care provider $.75 per day per licensed bed for this service. This is $273.75 per year, and the average nursing home stay is 2 years. Receiving over $500 for perhaps two 10-minute phone calls, checking off six questions, and sending the form to the nursing home is a lot of money. There is no obligation to find appropriate placement connected with the program. That is still the obligation of the person seeking placement, usually a family member or hospital discharge planner.
Redoing the reviews yearly seems futile. No one develops mental retardation during their lifetime. Mental illness can develop, but sometime during that year it would have been addressed, especially during quarterly care planning or when major changes occur. Relocation would have been investigated at that time, not during the PASARR.
So, has the PASARR been successful for the mentally ill elderly? Because there really is no choice in placement, it is just one more paper compliance procedure. It is not good use of the recipient's money. If it assured specialized care for these people, it would have been a positive action. But it did not.
Margaret Charlton, BA, MA
Kingwood Court Good Samaritan Center
For the most part, I feel that the screening allows nursing homes to accept those admissions they can appropriately treat and whose needs they can meet I sometimes wonder if some nursing homes shy away from those with positive screens even though the person could probably be appropriately placed in their facility. I don't think the problem is with the placement of mentally ill elderly; rather the problem is with the placement of the mentally retarded.
Eileen Jackson, RN, BSPA
West Hartford, Connecticut
As the Delta County OBRA Coordinator and the OBRA RN who does the medical history and examination on the Level II Assessments, I think that the PASARR effort has been successful in the following areas:
* All potential nursing home applicants, including those with private insurance and private pay, must be screened for evidence of mental illness and/or developmental disability before nursing home admission can occur. The screening of all applicants helps eliminate any discrimination that may exist. It also provides a screening that may or may not have been done otherwise. This could provide a direct benefit to someone who may be in need of mental health services but has never been identified.
* The OBRA mandate regulates the number of people admitted to nursing facilities. It does so by assessing whether a person's physical condition requires 24-hour nursing care. This allows people who truly need skilled nursing services to find an opening. Most nursing homes have waiting lists. If everyone and anyone was admitted to a nursing facility, there would never be an opening.
* The PASARR effort has opened the door and takes a closer look at a segment of the population that, in past times, has been admitted to nursing homes and forgotten. The federal mandate (OBRA '87) brought quality assurance in the nursing homes.
* As for the actual mental health needs of the elderly, the PASARR effort hopes that those needs are being identified and met with adequate service provision. Mental health services can be provided by the nursing home, community mental health providers, or other mental health providers.
In my opinion, the PASARR effort represents a country that has taken a stand for its forefathers and elders. The message is, "You may be growing old but if you need to go to a nursing home we are going to help the nursing homes take good care of your physical and mental health needs." Regulation is necessary.
The PASARR effort is a relatively small part of a very broad scope of nursing home regulations. OBRA governs not only mental health care but also physical nursing care. The mentally ill elderly may or may not benefit from this type of screening process. It depends on what recommendations are made and what mental health services will be provided. A big question remains: Who will follow up?
Nursing home surveying teams (auditors) go into the facilities and check if mental health recommendations have been followed. The county OBRA coordinator makes a recommendation to the Department of Community Health (DCH), and the DCH makes a determination back to the county. The county then notifies the nursing facility of the determination. Who is responsible for following up with the county's recommendations?
Delta county provides clinical support (mental health) services to the mentally ill elderly living in its nursing homes. The following services are provided to the residents: psychiatric evaluations, psychotropic medication reviews, nursing home mental health monitoring, psychological (behavior) consults, a resident emotional support group, and staff inservices and training. We are in the process of starting a staff stress management support group for the nurses and certified nursing assistants. Indirectly, this will have a positive effect on the care provided to the residents. We are developing a training program to assist the staff in working with dementia residents and residents with cognitive impairment. The program is designed to teach basic intervention techniques for dealing with residents with severe behavior problems. (I call it "CPR" for the Mind - Cognitive Perception with Redirection).
I think one reason why the PASARR effort has not been effective is because barriers have existed in the past that limit the collaboration of services provided to the nursing home. Unfortunately, most nursing home nurses are so busy just trying to provide quality, medical, subacute nursing care that they are not able to get into the mental health issues of all the residents. Unfortunately, time is also very limited for mental health professionals.
We need to realize that we are all in this together. We may have different roles to play, but we are in the same story. I would really like to see a happy ending! How about you?
Ronese L Kidd, RN
Delta County Community Mental Health
This question was submitted by Kathleen Sherrell, RN, PsyD of the Buehler Center on Aging, Chicago, Illinois and Kathleen C. Buckwalter, PhD, RN, FAAN of the Center on Aging, University of Iowa, Iowa City, Iowa. Their commentary follows:
The Pre- Admission Screening and Annual Resident Reviews (PASARR) mandate developed out of concern that mentally ill and mentally retarded persons were not receiving adequate or appropriate levels of care in nursing homes. It has emerged as one of the more controversial aspects of the Omnibus Budget Reconciliation Act (OBRA '87, Public Law No. 100-203), implemented in 1989. The PASARR requires preadmission screening and annual review for all residents (including those who are private payers) of Medicaid-certified nursing homes with mental illness (MI), mental retardation (MR), and related conditions (RC) (see definitions on page 51). In fact, the majority of initial PASARR evaluations were conducted on persons already residing in long-term care facilities (approximately 1 1,000 in the state of Illinois alone), in an effort to develop treatment recommendations for residents who may have been "warehoused." Among the fears related to this legislation were that large numbers of persons with MI and MR would be discharged from or not accepted into nursing homes, thus leaving them with nowhere to go. Further, Medicaid, which pays for the care of many of these individuals in nursing homes, does not always cover the cost of care in more independent settings such as group homes.
The PASARR process for prospective nursing home residents consists of three levels: screening, evaluation, and review. Level I prescreening is designed to determine whether candidates for nursing home admission have or are believed to have MI, MR, or RC. Persons identified through this intital screening process as having these conditions must undergo further evaluation by an mterdisciplinary team.
Level II evaluates persons identified through the Level I screening process as having MI, MR, or RC before admission. The purpose of this evaluation is to determine individual resident needs and set forth an appropriate plan of care to meet those needs. Facilities are responsible for the completion, or arranging for the completion, of the Level II evaluations.
Level III review determines whether the Level II process has been completed and whether the nursing facility placement and the proposed plan of care is appropriate. These same levels of the screening process are conducted annually for current residents of nursing facilities who have already been identified as having MI, MR, or RC, or who have developed new diagnoses related to these conditions. Moreover, an identical process was used when the PASARR was first implemented to evaluate persons already residing in long-term care facilities.
Ideally, the PASARR should assist in determining whether a prospective or current resident could either reside in a less restrictive setting (e.g., board and care home, assisted living facility) or benefit from more specialized and aggressive mental health treatment than can be provided in a particular facility. Moreover, the annual review for nursing home residents should ensure that their condition hasn't altered significantly such that nursing home care is no longer suited to their needs. Under terms of this legislation, MI or MR persons can be admitted to a nursing facility if they require nursing services, which also includes physical and occupational therapy. Residents are allowed to remain in the nursing home if they continue to need nursing services or have been a resident there for at least 30 consecutive months. If a resident remains in a nursing home while needing active mental health treatment, then that treatment must be provided. States can propose alternatives to the transfer of residents who need active mental health care and to date, 46 states have successfully done so.
PASARR: Success or Failure?
Nursing homes were originally developed to serve persons primarily with long-term physical needs. The population of these facilities has since expanded to include a significant proportion of residents with severe mental illness. Although we believe that the PASARR has noble goals and we do not intend to negate their intent, implementation of this plan has resulted in some less than desirable outcomes, not unlike the deinstitutionalization process of the 1960s. Indeed, there is a growing body of research supporting the fact that implementation of the PASARR may fall victim to some of the same obstacles as the community health movement, including: 1) confusing rules; 2) lack of clinical acumen on the part of policy makers; 3) lack of monitoring and evaluation; and 4) freezing of funds. Part of the problem is that data are often collected under the direction of different PASARR agents, with no uniformity of collection - some being extremely comprehensive, while others were totally inadequate. Thus, the data are essentially useless when it comes to outcomes research (Sherrell, 1991).
Briefly, a study conducted in Illinois by Kathleen Sherrell and Rachel Anderson on 335 older female residents with a diagnosis of schizophrenia who had undergone PASARR evaluation revealed no differences in levels of physical independence between the women with schizophrenia (mean age, 69.4 years) and those with other diagnoses (mean age, 74.8 years). Women with schizophrenia received significantly lower levels of individual therapy compared to other women residents, but there were no differences in the amount of group or family therapy provided. For older persons with schizophrenia, treatment recommendations did not differ as a function of age, activities of daily living capacity, dementia levels, family contact, or symptomatology. Older women with thought disorders were less likely to receive a recommendation for treatment. Results suggested that preadmission screening rarely includes specialized treatment and rehabilitation services for older persons with severe and persistent mental disorders and suggests that the mandated PASARR may not always result in improvement in care for older persons with MI in nursing homes. Indeed, findings of no differences in treatment recommendations from the Sherrell and Anderson report implicate a questionable data collection process (e.g., "sloppy data") and further suggest that the recommendations that were forthcoming from the PASARR evaluations were not reality based. That is, many of the recommendations made were for services or facilities that simply did not exist or were for a variety of reasons inaccessible, rendering them essentially useless to providers and consumers alike.
An important question for gerontological nurses to ask is: "Will PASARR yield lasting benefits for older persons in our nursing homes? Or, it this just another attempt (like the deinstitutionalization movement), which is not clearly guided, wisely delivered, reliably monitored, and adequately funded?
Because gerontological nurses are the most involved and knowledgeable about mentally ill residents in long-term care, those who feel that PASARR has been and is currently inadequate must respond by working with policy makers, conducting research, and improving implementation practices in their own settings.
Definitions of Ml, MR, and RC applicable to the PASARR process (Federal Register Rules and Regulations, 1992):
Mental Illness: Individuals are considered to have mental illness if they have a current diagnosis of a major mental disorder (as defined in the DSM-IIIR) such as schizophrenia, paranoia, major affective, schizoaffective disorders, atypical psychoses, and personality disorders. Those with organic brain syndrome disorders, such as Alzheimer's disease or other related disorders, were not included in this category.
The disorder must have resulted in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the individual's developmental stage. Individuals typically have limitations in at least one of the following characteristics on a continuing or intermittent basis: interpersonal functioning, concentration, persistence, pace, and adaptation to change.
The treatment history indicates that the individual has experienced at least one of the following: psychiatric treatment more intensive than outpatient care in the past 2 years, or due to the mental disorder, experienced an episode of significant disruption to the normal living situation within the past 2 years.
Mental Retardation: Individuals are considered to be mentally retarded if they have a level of retardation (mild, moderate, or profound) as described in the American Association of Mental Deficiency's Manual on Classification in Mental Retardation. Mental retardation refers to significantly sub-average general intelligence, existing concurrently with deficits in adaptive behavior and manifested during the developmental period.
Related Conditions: Individuals who have a severe, chronic disability mat meets the following conditions: 1) attributable to cerebral palsy or epilepsy; 2) any other condition such as autism and other MI found to be closely related to MR, because this condition results in impairment of general intellectual functioning or adaptive behavior and requires similar treatment or services; 3) manifested before the age of 22; 4) likely to continue indefinitely; 5) results in substantial functional limitations in three or more of the following areas of major life activity: self-care; understanding and use of language; learning; mobility; self-direction; capacity of independent living.
- Sherrell, K. (1991, Fall/Winter). Broken promises. Buehler Center on Aging Newsletter, 7(2), 1-3.