Transitional Planning and Transitions of Care
Jackie Birmingham
LEARNING OBJECTIVES
Upon completion of this section, the reader will be able to:
Define transitional planning as it relates to continuity of care.
List two federal Conditions of Participation that influence transitional care from acute care hospitals.
List other selected federal rules that have significance in transition planning.
Discuss factors that impact case management in cross-setting measures.
Describe specific topics related to selected levels of care to which inpatients are referred.
Describe Value-Based Purchasing and impact on transition management and readmissions.
List additional qualifications and experience needed to be a case manager who manages the transition of care as stated in discharge planning Conditions of Participation.
IMPORTANT TERMS AND CONCEPTS
Americans with Disabilities Act
Assessment Domains
Discharge Planning
Discharge Status Codes
Efficiency Score
Health Information Privacy and Accountability Act
Hospital Value-Based Purchasing
Improving Medicare Post-Acute Care Transformation Act
Key elements of care coordination
Levels of Care
Notice of Hospital Discharge
Olmstead Decision
Overlap of functions
Preadmission Screening and Resident Review
Privacy
Readmission
Surveyor guidelines
Transfer MS-DRG
Transitional Planning
Utilization Review
Introduction
A. The importance of transition planning is high on the need-to-know index for case managers regardless of experience level (e.g., novice, expert) or hierarchical position (e.g., frontline staff, management).
Transition planning is an example of demonstrating trust in other case managers across the care continuum.
Sending a patient to another care setting involves a handover of responsibility. The sending case manager presumes that the receiving case manager possesses the knowledge, experience, and adherence to case management practice standards in order to assume responsibility for the patient and his/her identified goals and concerns.
This handover requires the receiving case manager to perform case management activities in accordance with practice standards to ensure the patient’s case management needs are identified and addressed in an ongoing and progressive manner.
B. Transition management is not a new topic for case managers.
The article, One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transition Through Case Management, sets the stage for attention to the influence of case managers on patients as they move through the health care settings (Tahan, 2007).
In the 8 to 9 years since this definitive article was written, much has changed for case managers, not in the essential process or practice but in the health care industry as a whole.
One of the most significant change resulted from the Patient Protection and Affordable Care Act of 2010 with goals that have impact on payment for health care services based on quality and outcomes versus quantity of services provided (CMS-ACA, 2011).
The outcome of the success is based on the appropriate transition of patients, from acute care to self-care and all the steps in between.
C. The hallmark of patient-centered transition of care is based on a case manager’s ability to work with a team of professionals on both sides of the continuum.
All participants in the transitions of care must also work with the patient and family and determine what is the next best appropriate level of care in time and place, keeping in mind that the patient’s preferences met as far as is reasonably possible.
Nobody said it would be easy; however, it makes a huge difference for patients across the care continuum both your institution and the facilities and vendors that accept your transitioned patients.
Descriptions of Key Terms
A. Conditions of Participation—The Centers for Medicare and Medicaid Services (CMS) develops Conditions of Participation (CoPs) that health care organizations must meet to participate in the Medicare and Medicaid programs. These standards are used to improve quality and protect the health and safety of beneficiaries. The CMS also ensures that the standards of accrediting organizations recognized by the CMS, such as The Joint Commission (TJC) or the American Osteopathic Association (AOA), through a process called deeming, meet or exceed Medicare standards as stated in the CoPs. The standards apply to anyone receiving services, regardless of payment source.
Discharge planning—CoPs are associated directly with the hospital’s responsibility for discharge planning.
Patients’ rights—CoPs are associated with assuring that patients’ rights to freedom of choice and other issues are followed.
Medical records—CoPs are associated with the patient’s inpatient medical record and the need to ensure that the closed record contains information related to the course of the hospital stay and plans for follow-up care.
B. Continuity of care—The coordination of care received by a patient over time and across multiple health care providers and settings. This is usually of most concern during patient’s transition from one provider or level of care to another.
C. Discharge—The formal release, or signing out by a physician, of a patient from an episode of care. The episode of care can be in the form of hospital inpatient status, observation status, emergency room stay, or a clinic visit. A discharge can also be applied to an inpatient skilled nursing facility, acute and subacute rehabilitation facility, or a home health episode of care.
Discharge status—Disposition of the patient at discharge indicating to what level of care a patient has been transferred or discharged. Discharge status, particularly from acute care, has significance in how a hospital is paid and in how health care organizations track care. Disposition status also may refer to the patient’s state at the time of concluding care and services, which may be either alive or expired.
Leaving Against Medical Advice (LAMA) or Against Medical Advice (AMA)—A term used to describe a patient who is discharged from the hospital against the advice of his or her attending physician. The person signing out is usually asked to sign a form stating his or her awareness that the discharge is against medical advice.
Patient elopement—A term used to describe a situation in which a patient leaves without the knowledge of the hospital staff. The patient is then determined to be “missing.”
D. Discharge planning—The process of assessing the patient’s needs of care after discharge from a health care facility and ensuring that the necessary services are in place before discharge. This process ensures a patient’s timely, appropriate, and safe discharge to the next level of care or setting, including appropriate use of resources necessary for ongoing care.
E. Functional status—The assessment of an individual’s ability to manage his or her own care needs.
Activities of daily living (ADLs)—Activities that are considered an everyday part of normal life. These include dressing, bathing, toileting, transferring (e.g., moving from and into a chair), and eating. The functional levels of ADLs are used to measure the degree of impairment and can affect eligibility for certain types of insurance benefits.
Instrumental activities of daily living (IADLs)—Regularly necessary home management activities, including meal preparation, housework, grocery shopping, and other similar activities.
Executive function—An integrated set of cognitive abilities that allow an individual to process available information in planning, prioritizing, sequencing, self-monitoring, self-correcting, inhibiting, initiating, controlling, or altering behavior. It includes evaluation of such parameters as “capacity” and “competency.” Evaluating a patient’s executive function is a multidisciplinary process involving physicians, nurses, social workers, and other health care professionals and can, in some situations, involve the court system.
F. Handoff—The exchange of a patient’s care between incoming and outgoing caregivers; any transfer of role and responsibility from one person to another or one setting to another. Successful handoffs overcome barriers such as physical setting, social setting, language and communication barriers, and time and convenience.
G. Level of care—Different kinds and locations of care provided to patients, based on a scale of intensity or amount of care/services provided.
Acute level of care—The most intense level of care related to necessity for medical (physician) services.
Subacute level of care—The level of care that combines a high need for nursing, therapy, and physician services. Intermediate between acute and chronic, this level of care can be provided in acute care facilities or other facilities as determined by licensing in each state.
Transitional care unit (TCU)—A unit of care, usually in a hospital, that is dedicated to supporting a patient’s transition of care from acute to a lesser level of care. The level of care is similar to subacute.
Skilled nursing facility (SNF)—A facility offering 24-hour skilled nursing care along with rehabilitation services, such as physical, speech, and occupational therapy; assistance with personal care activities, such as eating, walking, toileting, and bathing; coordinated management of patient care; social services; and activities. Some nursing facilities offer specialized care programs for Alzheimer disease or other illnesses or short-term respite care for frail or disabled persons when a family member requires a break from providing care in the home. Payment for a stay in an SNF varies depending on the payer criteria, whether the patient was an inpatient in a hospital for 3 consecutive days, and the reason for admission.
Home health care services—Care provided to individuals and families in their place of residence for the purpose of promoting, maintaining, or restoring health, or for minimizing the effects of disability and illness, including terminal illness. Patients must meet the definition of homebound status and require intermittent professional services,
including nursing, physical therapy, occupational, and speech-language services, or social work services. Eligibility criteria for insurance coverage for home care services vary between payer groups.
Hospice—A program that provides special care for people who are near the end of life and for their families, either at home, in freestanding facilities, or within hospitals.
H. Prospective payment system (PPS)—A method of reimbursement used by the CMS that bases Medicare payments on a predetermined, fixed amount. The payment amount derived for a particular episode of care is based on a classification system of a specific level of care and an episode of care, for example, diagnosis-related groups (DRGs) classification for inpatient hospital services, resource utilization groups (RUGs) classification for nursing facilities, and home health resource groups (HHRGs) classification for home health agencies.
Diagnosis-related groups (DRGs)—The system used to pay for acute inpatient care that is based primarily on the patient’s principal diagnosis.
Resource utilization groups (RUGs)—The system used to pay for care provided in a nursing facility that is based on the amount, intensity, and type of “resources used,” including nursing care and therapies.
Home health resource groups (HHRGs)—The system used to pay home health agencies for services based on the resources used and the duration of the services.
I. Readmission—The admission of a patient back into the hospital, for the same disease or condition as the previous admission. Some payers review both admissions if they occur within a specified number of days, for example, 72 hours or 15 or 30 days. Readmission is the focus of a great deal of attention by health professionals and regulators especially with the advent of the Patient Protection and Affordable Care Act of 2010 and the proliferation of the Value-Based Purchasing Program and Hospital Readmissions Reduction Program.
J. Referral—The process of sending a patient from one practitioner to another for health care services; in the case of transitional planning, usually for services related to the current episode of care (e.g., rehabilitation consultation).
K. Transfer—The planned action of sending a patient from one place of care to another. It can be to the same level of care (acute to acute) or to a lower level of care (acute to postacute), or vice versa. The planning of the transfer involves notification of the next level of care and the transfer of necessary medical information.
L. Transfer/qualified DRG—A situation in which a patient’s care is coded as being within a predetermined list of DRGs, the patient is discharged to either a skilled nursing facility or home health agency for services related to the reason for hospitalization, and the patient is transferred before the national geometric length of stay for that DRG. Because the patient is determined to be leaving prior to the number of days in that DRG, and because the patient is receiving continuing care for which Medicare is paying, the hospital is paid only for the days of care provided and not the full DRG.
M. Transitional planning—The process that case managers apply to ensure that appropriate resources and services are provided to patients and
that these services are provided in the most appropriate setting or level of care, as delineated in the standards and guidelines of regulatory and accreditation agencies. It focuses on moving a patient from the most complex to less complex care settings (Commission for Case Manager Certification [CCMC], 2005).
that these services are provided in the most appropriate setting or level of care, as delineated in the standards and guidelines of regulatory and accreditation agencies. It focuses on moving a patient from the most complex to less complex care settings (Commission for Case Manager Certification [CCMC], 2005).
N. Transitional care—Transitional care includes all the services required to facilitate the coordination and continuity of health care as the patient moves between one health care service provider to another (Case Management Society of America [CMSA], 2010).
O. Transitions of care—Transitions of care is the movement of patients from one health care practitioner or setting to another as their condition and care needs change. This phrase is sometimes known as care transitions (CMSA, 2010).
Applicability to CMSA’s Standards of Practice
A. In its Standards of Practice for Case Management, the Case Management Society of America (CMSA) describes that case management practice extends across all health care settings, including payer, provider, government, employer, community, and home environment (CMSA, 2010).
B. CMSA explains that case management practice varies in degrees of complexity and comprehensiveness based on four factors:
The context of the care setting (e.g., wellness and prevention, acute, subacute, rehabilitative, or end of life)
The health conditions and needs of the patient population(s) served including those of the patients’ families
The reimbursement method applied for services rendered (payment), such as managed care, workers’ compensation, Medicare, or Medicaid
The health care professional discipline assuming the role of the case manager such as registered nurse, social worker, or rehabilitation counselor
C. Transitional and discharge planning standards are also addressed in the CMSA’s Case Management Standards of Practice. In this regard, the standards discuss the roles and responsibilities of the case manager in care planning, including identifying needs and developing short- and long-term goals, planning with the patient and family and obtaining their consent to the transitional plan, working with other professionals internal and external to the organization to meet the patient’s and family’s needs, brokering of services and procurement of health care resources as needed by the patient, and working in concert within payer demands and expectations.
D. This chapter describes transition planning across the continuum of health care and human services and focuses on the role of the case manager in these settings and the case management services provided. Because of the contemporary focus on transitions from acute care settings, content frequently mentions this care setting.
E. This chapter addresses case management practice that requires knowledge of and proficiency in the following practice standards: client assessment, problem/opportunity identification, planning, facilitation/coordination/collaboration, legal, ethics, advocacy, resource management, and stewardship.
Transitional Planning as it Relates to Continuity of Care
A. From the first introduction of the Standards of Practice (Case Management Society of America, 1995), to the revisions in 2002 (Case Management Society of America, 2002), and most recently in 2010 (CMSA, 2010), the term “transition of care” has been increasingly used and now can be found in one form or another in all of the Standards of Practice.
B. The Standards of Practice for Case Management: a Foundation for Care Coordination Across the Entire Care Continuum (McLaughlin Davis, 2014) provides a crosswalk between CMSA Standards, the Centers for Medicare and Medicaid (CMS) Condition of Participation, and the Joint Commission Standards. Each references the transition process and emphasizes the importance of transitioning patients through multiple levels of care in a timely manner with goals of satisfactory outcomes and financial efficiency.
C. Clarification about the essential definition of care coordination, as it relates to transition management, was addressed in the book, Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Shojania, McDonald, Wachter, & Owens, 2007).
The chapter, Definitions of Care Coordination and Related Terms (Shojania et al., 2007), shows the importance of care coordination, including transitions of care, and its relationship to quality improvement.
In this chapter, the editors list five key elements compromising care coordination.
Numerous participants are typically involved in care coordination.
Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient’s care.
In order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others’ roles and available resources.
In order to manage all required patient care activities, participants rely on exchange of information.
Integration of care activities has the goal of facilitating appropriate delivery of health care services.
D. Transition of care and discharge planning. Although the term used in this chapter, and in seminars, publications, and innovative projects, is frequently referred to as transition planning, the concept arises out of the practice and process referred to as discharge planning.
In the September 27, 2014 Interpretive Guidelines (CMS SOM-A, 2014) in the section on Discharge Planning, §482.43 Condition of Participation for Discharge Planning, CMS cited the distinction between these two terms, particularly in the use of either term, transition planning or discharge planning to denote facilitating care across the continuum:
Much of the interpretive guidance for these CoPs have been informed by newer research on care transitions, understood broadly. At the same time, the term discharge planning is used
both in Section 1861(ee) of the Social Security Act as well as in §482.43. In this guidance, therefore, we continue to use the term discharge planning.
The term discharge planning in the CMS COPs is centered on the practice as carried out in hospitals, as opposed to the practice of continuity of care for other non-hospital health care provider settings.
In contrast to the CMSA Standards of Practice that applies across the continuum, §482.43 of the Conditions of Participation for hospitals is targeted to patients in hospitals.
The amendment was passed in 1988 and the standards have been in effect since then, relatively unchanged. However, the process of transition planning has been adapted into COPs for other levels of care. For example, the COPs for home health agencies include the requirement of a policy for discharge of a patient from services (CMS-COP HHA, 2015).
Regardless of setting type, know the Conditions of Participation, which all include information on how to transition/discharge patients to the next level of care.
E. The role of a department manager in transition of care has distinct characteristics in addition to the functions of any person at the manager level (Box 13-1).
If you are a department manager that carries out transition of care functions, along with a myriad of other functions, review articles focused on managing transition of care from the managerial perspective.
F. It is necessary for the caser manager to differentiate the use of the terms transitional planning and discharge planning especially because of the subtle differences that exist between these two terms.
Transitional care planning is a general term that is used to describe the focused planning for patients who are moving through the health care system.
Discharge planning is a term generally applied to the process in which patients in an acute care setting are assessed for continuing care needs required after discharge from an acute setting.
Discharge planning is a specialty process within transitional planning.
BOX 13-1 Seven Domains of the Role of Transitions of Care Department Manager
Staffing and human resources
Compliance and accreditation
Discharge planning responsibilities
Utilization review responsibilities
Internal department relationships
External relationships
Revenue cycle accountability
G. Discharge planning is mandated by federal regulations. The process involves identifying patients who are at risk for adverse outcomes after discharge without specific interventions (Box 13-2).
H. Transitional planning has been mandated by federal agencies in the form of legislation, by accreditation agencies in the form of accreditation or professional performance standards, and by professional organizations and societies in the form of policies or practice guidelines.
I. Currently, there are specific case management standards and guidelines available that explain the roles and responsibilities of case managers in both transitional and discharge planning. These standards are advocated for by case management professional organizations such as the Commission for Case Manager Certification (CCMC), the CMSA and others that promote case management practice such as the American Nurses Association (ANA) and the National Association of Social Workers (NASW).
J. Transitional or discharge planning is one of the core knowledge areas usually covered in case management certification examinations. This topic addresses specific knowledge that pertains to case management practice, including the continuum of care, levels of care and services, care planning and goal setting, community services and resources, rehabilitation services and support programs, assistive technologies and durable medical equipment, continuity of care, and benefit programs.
BOX 13-2 Characteristics of Discharge Planning
All patients are required to have a discharge plan, but not all patients need the detailed interventions required by regulations.
Determining whether the patient’s ongoing needs are related to the reason for admission to an acute care setting, or if the ongoing needs are related to a chronic health condition or nonacute health problem, is involved. Reimbursement for postacute services depends on the origin of the need (acute vs. chronic).
Assessment of the patient’s postacute care needs is based on the patient’s predicted functional status and the capacity for self-care and management.
Level of care determinations is based on the patient’s assessed functional needs at or near the time of discharge. Functional assessment is a more reliable predictor of level of care than is the patient’s principal diagnosis.
The focus of discharge planning is moving the patient from the complex-acute care health system to the next appropriate level of care, which is usually less complex. Patients may need to move through two or three levels before they are in the least complex setting.
The least complex setting can be described as the level of care where the patient is stabilized from a functional point of view and has reached his or her maximum capacity for self-care.
Although case managers participate in discharge planning activities, it is the physician who determines the patient’s readiness for discharge and appropriateness of the next level of care based on the patient’s health condition and needs.
Federal Conditions of Participation that Influence Transitional Care From Acute Care Hospitals
A. The CM job description includes a variety of functions assigned to a department known by a variety of names (e.g., Case Management Department, Care Coordination Department, Care Continuity Department).
B. There are two basic regulations that influence CM job descriptions.
Those two basic regulations are utilization review (UR) and discharge planning (DP) (eCFR, 2015).
Some departments separate staff to perform the UR and DP functions; others combine the functions into a single position. Some facilities maintain two separate departments.
Regardless of the department configuration of the department, the two functions most closely related to transition management are UR and DP (Birmingham, Case Management: Two regulations with coexisting functions, 2007).
C. Utilization review. This section describes the overlap of utilization review and discharge planning as it affects case managers whose responsibilities include transition management.
Utilization review is an amendment to the Social Security Act that occurred in 1972.
The original rule stated that hospitals must review their own patient population for the following:
Appropriateness of admission
Continued stay
Professional services used
The terms medical necessity, reasonable, and necessary came into discussions about whether to admit, or not, a patient and, after admission, when and to what level to discharge.
In 1995, the UR process added the requirement that the hospital contract with a Professional Standards Review Organization (PSRO) for outside review.
A PSRO was charged with determining whether services were medically necessary, provided in accordance with federal standards and rendered in the appropriate setting (Neumann, 2012; Sprague, 2002).
The PSRO came to be known as the Quality Improvement Organizations (QIO) to more reflect its work on improving quality of care for Medicare beneficiaries.
In 2014, the CMS split two main QIO functions previously combined in one organization, which resulted in the two functions being managed by two separate entities contracting for each function, Beneficiary and Family-Centered Care (BFCC) and Quality Innovation Network (QIN). In the new structure, case review and quality improvement functions are performed by different contractors.
BFCC manages all beneficiary complaints, quality-of-care reviews, and appeals to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families. For additional information, see the section on the Important Message from Medicare.
QIN works regionally with providers and the community on multiple, data-driven quality initiatives to improve patient safety, reduce harm, and improve clinical care at their local and regional levels (HSAP, 2014).
Why talk about UR in a chapter on Transitions of Care? As mentioned, there is a significant overlap in functions of UR and DP.
UR monitors admission with the patient’s physician, monitors continued stay based on accepted criteria sets (e.g., InterQual, Milliman), and, by so doing, has a baseline for length of stay and can trigger more action in the discharge planning process when discharge is anticipated.
Both rules working in synergy result in a viable discharge plan as soon as the patient no longer meets medical necessity for continued stay.
These parallel functions mean that the patient will get the right care, at the right level at the right time.
D. Discharge planning—The four-stage process in transition planning as outlined by the CMS in the hospital COPs applies across the continuum. The stages are site neutral—regardless of where you work with patients, these steps can guide you in planning for the patient’s next phase of care.
The DP CoPs (and Section 1861(ee) of the Act on which the CoPs is based) provides for a four-stage discharge planning process:
Screening all inpatients to determine which ones are at risk of adverse health consequences postdischarge if they lack discharge planning
Evaluation of the postdischarge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one
Development of a discharge plan if indicated by the evaluation or at the request of the patient’s physician
Initiation of the implementation of the discharge plan prior to the discharge of an inpatient (CMS SOM-A, 2014)
Although listed in numbered phases, it is important to understand that the process is dynamic and not always linear. The following scenarios demonstrate this point:
On admission screening, a patient may appear to be appropriate for discharge to home with only family/caregiver support. However, as the hospitalization progresses, the patient’s condition may worsen (e.g., unplanned surgery, medical complication) and so transition needs should be reevaluated.
A patient is referred to a skilled nursing facility (SNF), but none meeting his needs are available on his expected date of discharge and he remains in the hospital a few more days getting the physical therapy for which he was referred. His evaluation for discharge level of care will be repeated. He may be able to go home with home physical therapy.
In the event that the patient is medically ready for discharge but no bed is available at the SNF, the CM works with the physician to assure that certification for continued stay and need for hospitalization because an appropriate SNF bed is unavailable.
A physician may certify or recertify need for continued hospitalization if the physician finds that the patient could receive proper treatment in an SNF, but no bed is available in a participating SNF.
If this is the basis for the physician’s certification or recertification, the required statement must so indicate; and the physician is expected to continue efforts to place the patient in a participating SNF as soon as a bed becomes available (LII Cornell, 2015).
Because in this case the patient may reach outlier status, CMs actively work on a patient’s discharge plan and must document all activities regarding the continued facility search.
UR committee collaboration is essential in this situation.
The constant movement of planning for transition is one of the greatest challenges facing case managers. The process is not complete until the patient moves to the subsequent appropriate and available level of care.
Other Selected Federal Rules that have Significance in Transition Planning
A. The Health Improvement Protection and Accountability Act of 1996 (HIPAA).
Title II of HIPAA changed the exchange of information between health care providers as no other law has.
The intent of Title II in the Law is to protect the privacy of health information of individuals.
The explanation of what can be exchanged for the purpose of coordinating care is best understood, when the fact that care transitions is considered by HIPAA as a treatment. Transition planning, aka discharge planning, is clearly a treatment.
Transition management is focused on the use of medical privacy of health information and the sharing or exchange of protected health information (PHI) when the information is exchanged electronically. The Health Information Technology for Economic and Clinical Health Act (HITECH) covers the requirements of PHI, but for purposes of this chapter, the focus will be on what type of information can be shared, not how it is shared.
Frequently, questions arise regarding the consent to share information for transition/discharge planning.
HIPAA does not require patients to sign consent forms before doctors, hospitals, or ambulances may share information for treatment purposes (MLN-HIPAA, 2014).
However, because transition management is regarded as a treatment, the CM may reinforce that the patient signed the consent for treatment and services upon admission to the hospital.
When a patient is admitted through the emergency department, there is a higher risk for not having obtained a signature authorizing consent to treatment. The CM ensures a consent form has been signed. Regardless of the signature status, the patient (and family) must be kept aware of the transition planning process.
Please note that HIPAA is a federal law. Many states maintain separate legislation and regulation. State-specific regulations regarding PHI sharing, especially pertaining to behavioral health issues, are frequently more restrictive. Know the laws and regulations governing PHI within your particular jurisdiction.
B. Preadmission Screening and Resident Review (PASRR).
PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long-term care. It requires that
All applicants to a Medicaid-certified nursing facility be evaluated for mental illness and/or intellectual disability
All applicants be offered the most appropriate setting for their needs (e.g., community, SNF, acute hospital)
All applicants receive the services they need in those settings (PASRR, 2015)
PASRR programs are managed on a state-by-state process, meaning that each state has its own rules for how the federal mandate is run.
Most states require that all applicants for nursing home care have a level I PASRR screen by hospital staff to determine if there is evidence of a mental illness (MI) or developmental disability (DD) that requires further evaluation.
If the patient demonstrates any of the state’s criteria for MI/DD, the patient may require further evaluation by a specialized, approved health care professional who must conduct what is known as a level II evaluation.
The process of completing the PASRR requirement for patients being considered for nursing home placement can take several days; therefore, persons doing transition management should start the PASRR level I as soon as that level of care is being considered. If you are unsure about anything to do with PASRR, there is a PASRR technical organization, which provides free, up-to-date assistance (PTAC-PASRR, 2015).
C. Olmstead v. L.C.
On June 22, 1999, the Supreme Court of the United States held that unjustified segregation of persons with disabilities constitutes discrimination in violation of title II of the Americans with Disabilities Act (ADA).
The Court held that public entities must provide community-based services to persons with disabilities when the following exist:
Such services are appropriate.
The affected persons do not oppose community-based treatment.
Community-based services can be reasonably accommodated, taking into account the resources available to the public entity and the needs of others who are receiving disability services from the entity (ADA-Olmstead, 2015).
A case manager participating in transition management for person with disabilities must assure that the individual with disabilities is discharged to the least restrictive environment, regardless of their previous level of care.
D. The Americans with Disabilities Act. The ADA is mentioned in the CoPs for DP (CMS SOM-A, 2014). Case managers must assess individuals qualified as disabled for special needs as part of the transition planning (OCR-ADA 504, 2015).
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