Transition Center Nurses for MFP

Christine Trimboli RN & Laura Bingell RN

UAS and PRI/Screen forTransition Specialists

“Open Doors is a Money Follows the Person program of New York Association on Independent Living under contract with New York State Department of Health. This document was developed under grant CFDA 93.971 from the U.S. Department of Health and Human Services, Center for Medicare &Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government.”

DefinitionsPRI

• Patient Review InstrumentA clinical tool used to assess a person’s condition and the amount of care required for admission to an institutional setting and before discharge.Screen - A supplement done to better determine mental health, cognitive factors and resources available.

UAS• Uniform Assessment System A comprehensive assessment system designed to determine the amount of care requiredin home and communitybased settings.

It includes supplements forFunctional status andMental Health status.

(Adult, 4-17 years, 0-3 years)

• PRI - RN (Nurse Evaluator- NE)

• Screen – RN or SW• Qualified through

NYSDOH contracted training program

PRI and Screen UAS• RN – SW (Assessor)• Qualified by

NYSDOH Health Commerce

• Web based training

Who Does It?

Where Each is Conducted

• PRI- in the community, while hospitalized or on ‘swing bed’ status, and prior to leaving NH

• UAS- in community,in facility prior to leaving, used by MLTCs and RRDCs for waivers to determine if minimum LOC is met

https://www.health.ny.gov/health_care/medicaid/publications/gis/15ma011.htm

Nursing Home

Resident

• SC will need a PRI and Screen less than 90 days old for submission to RRDC with waiver application

Waiver participant

• UAS to be completed by NE (usually CHHA or LDSS) within 90 days of return to the community

MLTC • Contract with own NE/Agency

How Outcomes are Measured

• CAPs – Clinical Assessment Protocols

• RUGs - Resource Utilization Groups Classification

• NFLOC – Nursing Facility Level of Care

What Do These Mean?

CAPSClinical Assessment ProtocolKey factors in an individual’s life that indicate areas requiring additional needs and supports.

4 Areas of Focus• Functional Performance• Cognition and Mental Health• Social Life• Clinical Issues

• Resource Utilization Groups• Major classifications that people are assigned

to based on clinical characteristics, functional status, complexity of care needed and cognitive status.

• The primary purpose of assigning a RUGs category is to calculate the relative cost for care in a facility.

NFLOCNursing Facility Level of Care

• Based on scoring index that is uniform for all UAS assessments and programs now in NYS

• Uses information from the following portions of assessment-Cognitive, Communication, Vision, Mood and Behavior, Functional Status, Continence and Nutritional Status

• Responses and observations in these areas are converted into points

• The higher the number the greater need for care

5 or greater qualifies for waiver services

Focus on UAS

Purpose of UAS• Evaluates individual’s health status/strengths and

guides the development of a plan of care • Assists with program eligibility determinations and

identification of program options • Improves care coordination and facilitates service

delivery • Improves communication about assessment

information and reduces redundancy • Ensures that individuals receive the right care, within

the right setting, and at the right time

UAS Process• Interview and observe the person, then consult with

a family member(s), PCP and/or other caregiver(s). Focus on whether the person is actively managing tasks of daily living, not whether the caregiver(s) believe the person might be capable of doing so.

• THE FOCUS IS ON ACTUAL PERFORMANCE.

UAS - Areas Evaluated• Cognition- Short Term and Procedural• Communication and Vision• Mood and Behavior• Functional Status – ADL, IADL, Mobility• Continence• Nutritional Status

UAS Components

Community Assessment

Functional Assessment

Mental HealthAssessment

Bathing, personal hygiene,dressing of lower body, locomotion, and change in ADL status

Disease dx (schizophrenia), abnormal thought process, delusions, tobacco, alcohol, substance abuse, depression, cognitive performance

CODING Choices Related to Function

IndependentModified independenceMinimally impairedModerately impaired Severely impaired No discernable consciousness, coma

What person has actually done in the past

3 days

What person is capable of doing in the

professional opinion of evaluator

Areas Evaluated In Mental HealthSupplement

• Mental Health Service History• Mental State Indicators

– Self-deprecation, expressions of guilt/shame, irritability, hopelessness, inflated self-worth, pressured speech, racing thoughts, obsessive/compulsive behaviors, intrusive thoughts/flashbacks, substance use, unusual physical movements, hygiene, harm to self and/or others (attempts/ideations), suicide intent, expressions of concern by family, tendency toward violence, police intervention, stress/trauma, medications, family conflict

Mental Health Coding Choices

NeverMore than 1 year ago 31 days to 1 year ago 8 to 30 days ago 4 to 7 days ago In last 3 days

6/12/14 Announcement from TBI Services Coordinating Council

“There is great concern many of New York’s most vulnerable citizens, those with a documented traumatic brain injury (TBI) whom are currently being served by the New York State Department of Health TBI waiver, will be inaccurately assessed as not meeting level of care criterion, particularly if their primary disabilities are cognitive/behavioral and not physical.”

The Alzheimer’s Association “ The need for assistance with activities of daily living (ADLs) must be defined to include verbal assistance

and the extent or severity of need must be determined by the duration of the assistance required, not the type of assistance.”

“Level-of-care criteria must include measures of individuals’ need for supervision to protect them from the negative effects of impaired judgment

and decision-making; impulsive inappropriate or disruptive behaviors; and other potentially harmful behavior such as wandering.

These measures must be weighted appropriately so that people with severe impairments will be eligible.”

Focus on H/C PRI and Screen

What is a PRI?• HC-PRI = Hospital & Community Patient

Review Instrument• Assessment tool developed by NYSDOH• Determines LOC and appropriateness of

placement• Assesses physical, medical, & cognitive

characteristics• Determines selected services

Sections of a PRI• Administrative Data• Medical Events• Activities of Daily Living (ADLs)• Behaviors• Specialized Services• Diagnosis• Plan Of Care Summary

How a PRI Works

Category Defines

• Medical conditions and treatments

• Need for rehabilitation

• Mental Health and behavior

Scoring Reflects

• How much assistance or supervision is required with ADLs

Scoring -Eating How individual consumes food

Level of independence with eating

How maintains nutrition

Need for verbal cuing

Need for assist opening containers

Need for assist cutting food

Scoring- Transfer Is physical assistance required

Are transfers independent

Intermittent supervision needed

Assist for guidance, safety, steadiness

Total dependence

Equipment/Hoyer Lift/ Gait Belt

Scoring- Toileting Ability to get to toilet, bedpan, or commode

Ability to maintain personal hygiene

Ability to appropriately adjust clothing

Assessing for continence/incontinence

Incontinence briefs or pads

Toileting/bowel regime

Categories - Special Needs Groups

Heavy Rehabilitation

Clinically Complex

Severe Behavioral

Reduced Physical

Functioning

• Requires restorative PT or OT

• 5 sessions/week• Min. of 2.5 hrs/week• Must be likely to

improve

• Does not meet HR criteria • ADL score of 5 or more• 1 or more of following:

stage 4 decubitus, suctioning, comatose, nasal gastric feeding, parenteral feeding, quadriplegia, or multiple sclerosis (MS)

• Doesn’t meet criteria for prior categories• ADL score less than 5• One or more of following:

dehydration wound care internal bleeding stasis ulcerdaily oxygen chemotherapydialysis urinary tract infection terminal illness blood transfusions1 or more MD visits/week cerebral palsy

• Exhibits behavior- infantile, disruptive, verbally/socially inappropriate or physical aggression

• Behaviors must be documented

• Behaviors 1/week for past 4 weeks

• Remaining individuals who did not meet prior criteria

• More custodial

• Can present challenge for appropriate placement

What is a Screen?Screen validates

• Level of care needed• Qualification for NH placement• Qualification for HCBS• Need for supervision and oversight based on

diagnoses of dementia/Alzheimer’s

Two Purposes of the Screen• To determine potential for appropriate

care in a setting other than a RHCF• To assess those recommended for RHCF

for possible mental illness, and developmental disabilities- requiring additional review instruments

May trigger a ‘Community Based Assessment’

Community Based Assessment

To determine resources available to an individual that would support living in the community.

• A person’s environment• Informal supports• Economic resources• Physical/Mental needs

Questions?

Laura Bingell RNlbingell@ilny.org(607)962-8225

Christine Trimboli RNctrimboli@ilny.org

(518)538-6767

https://www.health.ny.gov/forms/doh-694.pdfWeb address to see PRI/Screen forms.

mailto:lbingell@ilny.orgmailto:ctrimboli@ilny.orghttps://www.health.ny.gov/forms/doh-694.pdf

UAS and PRI/Screen for�Transition Specialists DefinitionsPRI and Screen UASWhere Each is ConductedSlide Number 5How Outcomes are MeasuredCAPSRUGsSlide Number 9NFLOCFocus on UASPurpose of UASUAS ProcessUAS - Areas EvaluatedUAS ComponentsCODING Choices Related to FunctionSlide Number 17Areas Evaluated In Mental Health�SupplementMental Health Coding Choices6/12/14 Announcement from �TBI Services Coordinating CouncilThe Alzheimer’s Association �Focus on H/C PRI and ScreenWhat is a PRI?Sections of a PRIHow a PRI WorksScoring -EatingScoring- TransferScoring- Toileting�Categories - Special Needs Groups�Slide Number 30Slide Number 31Slide Number 32What is a Screen? Two Purposes of the ScreenCommunity Based AssessmentQuestions?