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Indiana’s Pre-Admission Screening: A Critical Look at the Nursing Home Admission Process

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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Emily Hancock

Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Emily Hancock

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Indiana’s Pre-Admission Screening: A Critical Look at the Nursing Home Admission Process Indiana’s Pre-Admission Screening: A Critical Look at the Nursing Home Admission Process Presentation Transcript

  • 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