Published on October 19, 2007
Indiana’s Pre-Admission Screening: A Critical Look at the Nursing Home Admission Process Emily F. Hancock, Pharm.D. Health Policy Advisor State of Indiana Office of Medicaid Policy and Planning
Problem Statement The majority of Nursing Facility (NF) admissions come directly from hospital discharges. The ease of admitting individuals quickly into NFs, coupled with the lack of a timely, clinically-driven approval process, has led many individuals to be admitted into NFs that would have been more appropriate to receive care in home and community based services (HCBS). 2
Goal Reduce and eliminate unnecessary admissions to Indiana NFs 3
Objectives Use a clinical process to: Determine Level of Care (LOC) Authorize NF admissions through Prior Authorization (PA) Access medical needs for service planning Regularly re-establish need for NF care Utilize Area Agencies on Aging (AAA) for long term care screening and options counseling 4
Current Process Issue #1 PAS ≠ Screening Screening and assessment are different processes PAS is not operationalized as true screening PAS process is currently used to gain admission to NF PAS generally occurs after the fact 5
Current Process Issue #2 PAS + LOC = Eligibility Screen (e-screen) The Eligibility Screen (in INSITE) contains the PAS instrument incorporated with LOC PAS instrument and LOC process need to be updated 6
Current Process Issue #3 PAS = 450B + e screen Physician attestation required for NF admission on 450B form 450B form is a weak, obsolete system; only used to trigger payment to NF 7
Current Process Issue #4 Ø Clinician PAS is not a clinically-driven process PAS does not prove medical necessity 8
Current Process Issue #5 Ø Timely PAS most often occurs long after an individual has settled in the NF The longer an individual stays in a NF, the harder it becomes to leave 9
Current Process Issue #6 Ø Prior Authorization denials 450B form is currently the only PA process Retrospectively, PAs are rarely denied 10
Solution #1 Adopt an instrument that: Is widely distributed, validated and normalized Has utility for LOC, screening and assessment Possesses ease of administration Correlates service plan to need Serves as a mechanism to measure quality throughout the Long Term Care array MDS-HC 11
Solution #2 Emphasize the role of the AAAs Statewide ADRCs Focus on LTC screening and counseling Partner with hospital discharge planners Incentives for HCBS placement 12
Solution #3 Implement PA for admission into NFs Care Management Organization (CMO) Medicare Special Needs Plan (SNP) PA determines medical necessity Retire the 450B form 13
Solution #4 Active Case-Management Continual monitoring of dual-eligible individuals on a NF Medicare stay Regularly reassess need for NF care Develop discharge plan based on service need • Discern local capacity • Establish medical home • Transition coordination 14
Possible Arguments The PA requirement would result in hospitals keeping patients longer, thereby increasing hospital costs The Office of Medicaid Policy and Planning will institute a process in support of hospital discharge planning that will ensure appropriate release The AAAs will not be used in the process The AAAs will be vital in the role of long term care screening and options counseling 15
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