Serious Mental Illness in Nursing Homes: Stakeholder Perspectives on the Federal Preadmission Screening Program

Abstract

The federal Preadmission Screening and Resident Review (PASRR) program was enacted in the 1980s amid concerns surrounding the quality of nursing home (NH) care. This program is meant to serve as a tool to assist with level of care determinations for NH applicants with serious mental illness (SMI) and was intended to limit the growth in the number of NH residents with SMI. Despite this policy effort, the prevalence of SMI in NHs has continued to increase, and little is known about the mechanisms driving the heterogeneous and suboptimal administration of the PASRR program, absent routine evaluative efforts. We conducted 20 semi-structured interviews with state and national stakeholders to identify factors affecting PASRR program administration and NH care for residents with SMI. Stakeholders expressed concern regarding fragmentation, specifically lack of clarity in the value of assessments beyond a regulatory requirement. Additionally, they cited variable program administration as contributing to fragmented communication patterns and inconsistent training across jurisdictions. Given the number of people with SMI currently residing in NHs, policy and practice should take a person-centered approach to assess how PASRR can be better used to support resident needs.

Keywords: nursing facilities; nursing homes; preadmission screening; serious mental illness.

Figure 1.

Diagram of the federal PASRR screening process for non-waiver beneficiaries in Minnesota. Non-Waiver beneficiaries are those who are not currently covered under a home and community-based waiver or managed care plan. ^PASRR Level I: Completed by nursing staff, discharge planners, or social workers. Form is competed for all persons who wish to enter a Medicated-certified NH in Minnesota.PASRR Level I screening questions: (1) Does the person have a DSM diagnoses of a major mental disorder? (2) Did this significantly impair psychosocial function in the last 3–6 months? (3) Does the person’s treatment history within the last 2-years indicate a psychiatric treatment more intensive than outpatient therapy or “an episode of significant disruption to the normal living situation” which required supportive services or involvement by law enforcement or housingPositive identification of suicidal ideation during the Level I assessment automatically triggers a Level II assessment.