OBRA/PASRR

For those with MENTAL ILLNESS

(See separate page for those with Developmental Disabilities)

Please note: UMass Medical School (UMMS) assumed responsiblity for OBRA/PASRR on September 1, 2017.

Sections:

What is OBRA?
Does the patient require a Level II screen?
Previous screen? Is it still valid?

Abbreviated Screens
Indications - Mental Illness
Exemptions (Require Exemption letter from OBRA office/UMMS)
Categorical Determinations (Medical conditions that mean Level II screen is not required.)

Special Situations
Patients seen in ED or on Observation Status
Dual Diagnoses: BOTH Mental Illness and Intellectual or Developmental Disabilities

Completing the Level II screen form - FAQs
For more information (contact info)

Also see:  OBRA FAQs

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What is OBRA?

The Omnibus Budget Reconciliation Act of 1987 (OBRA) is a federal law that mandates Pre-Admission Screening/Annual Resident Review (PASARR) for those persons regardless of payer source who have a major mental illness or a developmental disability and who are seeking nursing facility level of care. The purpose of these evaluations is to determine the appropriateness of the placement in a nursing facility setting, to divert persons whose illness prevents them from functioning satisfactorily in such a setting and to make initial recommendations for treatment within a nursing facility.

NOTE: this page focuses on criteria, exemptions and process for those with a major mental illness. Note the separate page and different process for those with Developmental Disabilities.

Level I and Level II- ALL patients going to a nursing facility should receive a Level I screening. This screen determines whether or not a full Level II screen is required. This Level II screen is the "OBRA form" that is familiar to social workers and that we help facilitate.

We are a "delegated hospital" which means our staff can complete the mental illness Level II screen rather than neediing to refer to an outside agency.

The screen must be completed before the nursing facility can admit the patient from an inpatient setting. (See Special Situations: Patients seen in ED or on Observation Status)

 

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Does the patient require a Level II screen?

Step 1- Does the patient already have a current OBRA on file and is it still valid?

Step 2- Does the patient have a serious mental illness?

Step 3- Does the patient have a medical condition that meets the Categorical Determinations criteria?

Step 4- Does the patient meet an Exemption?

 

Step 1: Does the patient already have a current OBRA on file and is it still valid?

If the patient was admitted from a SNF with a significant history of mental illness, he or she may already have a Level II screen on file. Call UMMS to inquire- 866-385-0933 . (Please have the client's name and social security number at the ready.)

Does the patient need a new Level II screen? (If so please note you can do an abbreviated screen.)

A Level II mental illness screening is valid until one or more of the following:

• An inpatient psychiatric hospitalization.
• A significant change in mental status has occurred that results in a new psychiatric diagnosis for a nursing facility resident.
• A nursing home resident is discharged to the community, decompensates and wishes to be re-admitted to any nursing facility.
  • This includes any discharge from the facility- such as due to a medical hospitalization beyond the 20 day bed-hold.
  • If patient returns to the same facility before the end of the 20 day bed-hold a new screen is not required.
  • If a patient is admitted for a medical admission and is discharged to another SNF a new screen is not required. (The orignal facility should forward the screen to the new facility.) However if admitted for a psychiatric admission would require a new screen.
• A federal or state level auditor requests a screening.

If none of the above are true, the previous screen is still valid and we do not need to complete a new one.

If the patient has a previous screen that is no longer valid based on one or more of the above - we may do an Abbreviated Screen:

Abbreviated Screens: if a patient has a previous screen on file, but the previous screen is no longer valid (see above), we can do an abbreviated screen. An abbreviated screen is only pages 1, 4, and 12 through 16. Make sure to check the "Subsequent Review" checkbox on p. 1.

 

Step 2: Indications - Mental Illness

Does the patient have a serious mental illness? Note: OBRA screening is not yet using DSM 5 terminology and criteria (as of fall 2014).

• Psychosis
  • Schizophrenia- all types
  • Paranoia- all types which are NOT medication induced
  • Atypical psychosis- all types which are NOT medication induced
• Affective Disorders
  • Schizoaffective disorder
  • Bipolar disorder
  • Unipolar/Major depression- only those of longstanding nature of at least 10 year duration with at least ONE of the following:
    • inpatient psychiatric treatment OR
    • ElectroConvulsive Treatment (ECT) OR
    • medications
• Anxiety & Somatoform disorders
  • Only those that:
    • are of at least 2 years in duration with symptoms in the last 6 months AND
    • have required inpatient psychiatric treatment with subsequent need for mental health follow-up services AND
    • Requires medication to decrease symptomatology which significantly interferes with the individual's ability to meet his/her activities of daily living needs.
  • Screenable anxiety and Somatoform Disorders:
    • Panic disorder, with or without agoraphobia
    • Obsessive-compulsive disorder
    • All dissociative disorders, including amnesia, fugue, identity and not otherwise specified
    • Generalized anxiety disorder
    • Conversion disorder
    • Agoraphobia with panic disorder
    • Post Traumatic Stress Disorder
    • Depersonalization disorder
    • Specific phobia
    • Somatization disorder
• Or when there is a "significant change" in a nursing facility resident's behavioral, mental or emotional status. "Significant change" is defined as:
  • the admission to a psychiatric or geripsychiatric unit for treatment of symptoms other than those secondary to a diagnosis of dementia, regardless of whether or not the person was identified and approved by previous (OBRA) pre-admission screenings
  • the facilty resident has a new diagnosis that meets the criteria on the "indications" list above.

If the patient has none of the above conditions as defined above, the patient does not meet the criteria for a Serious Mental Illness and does not need a Level II screen.

If the patient has one or more of the above conditions as defined, proceed to the next steps.

 

Step 3: Exemptions

Since OBRA preadmission screening is meant to ensure those with significant needs are getting appropriate services, those with lower levels of need may be exempted.  But using these exemptions requires getting an exemption letter from UMMS.

IF the patient otherwise meets criteria for the preadmission screen, but has had NONE of the following, they will likely be exempt.

Within the past TWO years, the individual has NOT:

1. had any psychiatric hospitalizations
2. been in a psychiatric day treatment, respite or crisis stabilization program
3. been in a residential treatment setting due to a mental disorder (MI or DD)
4. experienced intervention by housing or law enforcement officials due to a mental disorder
5. required support services to maintain functioning at home due to a mental disorder (e.g., PACE, CBFS, DMH, CM).
   
Or received any of the following interventions (new- added 9/17)
6. Substance Abuse Intervention
7. Interventions related to signs of impaired interpersonal functioning, including excessive irritability, fear of strangers or illogical comments
8. Interventions related to signs of impaired concentration/task- difficulty concentrating, loss of interest, keeping pace
9. Interventions related signs of impaired adaptability to change- threats against others, suicidal ideation/attempts, self-injurious

If the answer to ALL of these questions is no, indicate this on the Screening questionnaire. If UMMS agrees that the patient is exempt, they will send the "Pre-Admission Screening and Resident Review (PASRR) Level II Exemption Notification" letter to the nursing home.

• Sample Exemption Letter
• What to do with the Exemption Letter
  • If the patient has MassHealth please ensure that the case manager gets a copy (directly from UMMS or from you) and a copy is placed in the medical record.
  • If the patient does not have MassHealth please place the letter in the medical record.

If the patient had ANY of the services or interventions in 1-9 above within the past 2 years, they are considered to have serious mental illness. Continue to next step- Categorical Determinations.

 

Step 4- Categorial Determinations (Medical conditions that mean Level II screen is not required.)

Categorical Determinations are medical conditions, that, if properly documented, mean the patient does not require a Level II screen.

• Dementia - documentation must include one or more of the following: results from scans (CT, PET, MRI, etc) documenting significant atrophy, neuropsychological testing documenting dementia by psychometric testing, nursing and/or social work notes citing the progressive decline of cognitive and behavioral functioning over a specified period of time. An MD MUST include the diagnosis of dementia on the official list of conditions receiving treatment.
• Congestive heart failure- END STAGE disease documented with 24-hour oxygen order
• Chronic obstructive pulmonary disease- END STAGE disease documented with 24-hour oxygen order
• Parkinson's disease- END STAGE disease documented AND the individual is Bedbound or Bed-to-chair
• Huntington's chorea- END STAGE disease documented AND the individual is Bedbound or Bed-to-chair
• Amyotrophic lateral sclerosis- END STAGE disease documented AND the individual is Bedbound or Bed-to-chair
• Severe head injury - with inability to diagnose source of behavior as due to head injury or mental illness (those sustained before age 22 should be reported to DDS)
• Comatose or ventilator dependency
• Terminal illness- prognosis of six months or less signed by physician
• Convalescent care of thirty days or less immediately following an acute hospitalization (Paperwork signed by physician must specify 30 days or less; "short-term" is insufficient.)
  • Note- must have had an acute hospitalization; neither an ED visit nor an Observation stay qualifies as a convalescent care Categorical Determination. More on patients seen in the ED or on Observation status.

If the patient has any of the above conditions as defined above, a Level II screen is not required. (No exemption letter is required either.)

If the patient has none of the above conditions as defined above, and you've completed all of the "steps", complete the Level II screen.

 

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Special Situations

Patients seen in ED or in Observation Status

For patients who are living in a community setting and present to the ED or are admitted under observation status and will be going to a SNF who require a screen: UMMS prefers that the hospital complete the Level II screen, however, the SNF may admit as an emergency admission and contact UMMS to conduct the screen at the facility.

Note: The 30 day rehabilitation exemption does not apply when patient is admitted to a SNF directly from the ED or an Observation Status.

 

Dual Diagnoses: BOTH Mental Illness and Intellectual or Developmental Disabilities

Those with dual diagnoses- who meet criteria for both the mental illness and developmental disabilities types of screens - require both types of screens. More information for those with intellectual or developmental disabilities.

 

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Completing the Level II Screen Form - FAQs

• The form must be completed by at least a master's level licensed clinician (LICSW, LCSW, RN, CNS/NP, LMHC, Phd/MA in psychology, MD or DO).
• UMMS does not require certain role groups to complete certain parts of the form- which discipline is responsible for which components is a MGH intra-departmental decision.
• The patient refuses to sign the release of information (p 15)- this release is recommended but not mandatory. OBRA is a required screening under federal law, so the screen may take place in the absence of signed patient release.
• If the patient has a previous Level II screen on file, and a new one is indicated, you may do an Abbreviated Screen.
• Remember to please give this list to patients and families: OBRA Community Based Services Resource List
• When completed:
  • Fax a copy to UMass Medical School Fax: 508-856-7696
    • Important: please indicate on the cover sheet that it is a completed Level II screen.
      • This will be the trigger for them to call you within the hour to approve transfer.
      • Please ensure that your contact info on the cover sheet is complete and legible, as it is not included in the form itself.
  • One copy should be maintained with the hospital records
  • One copy should be included with the discharge paperwork to the nursing facility

 

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For more information:


UMass Medical School
Phone: 866-385-0933
TTY: 508-856-7697
Fax: 508-856-7696
Email:    DMHPASRR@umassmed.edu


Also see our OBRA FAQs page.

 

Rev 9/17

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