North Carolina has reduced the number of people with severe mental illness being relegated to adult-care homes in the state, but in the process has made it harder for some people to get into such facilities when necessary.
Social workers say delays caused by a screening system put in place in January to ensure that people with mental illness are not moved into assisted living facilities when they could live more independently actually could endanger some clients who are no longer able to live safely by themselves or with family and need new living arrangements quickly. The delays also inadvertently have left some patients sitting in hospital rooms for days after they were medically ready to leave.
The state Department of Health and Human Services says it is aware of the problems and is working to speed up the process by the beginning of 2014.
We have complained to everyone who would listen, said Susan McCracken, director of Lincoln County Social Services, who has been frustrated since the state made changes to the way people are admitted to adult care homes.
The problem largely arises from paperwork or in the age of electronic record-keeping, an online form that must be completed for every individual in North Carolina asking to move into an adult care home, also called an assisted-living facility.
The form is the Pre-Admission Screening and Resident Review, or PASRR, which people involved in the process pronounce, PASS-arr.
Aiming for best possible care
North Carolina has long required the completion of a PASRR for anyone asking to move into a skilled nursing home, the form of long-term care designed for patients with more serious medical conditions. But in January, it began requiring the form as well for anyone seeking to move into all adult-care homes, also referred to as assisted living facilities.
The change was the result of a landmark agreement reached in August 2012 between the state and the federal government. The agreement was supposed to provide thousands of people with mental illness a way out of adult-care homes and hospitals.
The state entered into the agreement to avoid a federal lawsuit over possible violations of the Americans with Disabilities Act. A nonprofit advocacy group, Disability Rights North Carolina, had complained that the state was wrongly confining thousands of people to adult-care homes and institutions. Those people must be offered other, less restrictive options with supportive services in the larger community, the group said, including group homes or rental apartments or houses.
To fulfill the agreement, the state Department of Health and Human Services now uses the PASRR form to try to identify any individual with severe and persistent mental illness who is asking to move into an adult-care home.
Those with a mental illness still can choose to live in an adult care home, but they must also be offered other options, such as help finding an apartment and connection to community services. These could include transportation, counseling and job training and placement.
By diverting some people with mental illness from adult-care homes, the state is keeping with modern practice that says the mentally ill are best served by living in the community and not segregated or warehoused in institutions. The approach also reduces the likelihood of their being placed in facilities not equipped to help them, where they may become a danger to themselves or to others.
Form combs patients history
The PASRR is a multi-page form that asks whether the person has been diagnosed with or is suspected to have any of a range of cognitive impairments, developmental disabilities, mental health disorders or behavioral issues; whether they are taking psychiatric medications; and if so, which ones.
The PASRR was launched as an online tool that must be completed by a health-care professional, and that cant be someone who works for an adult care home.
Once submitted, its automatically screened by a DHHS computer that looks for indicators of severe and persistent mental illness. If the computer finds none, the applicant is cleared within minutes to be placed in an adult care home. If it finds indicators, the person must be scheduled for a face-to-face assessment with a mental-health professional.
The form would be required for a person who has been living alone or with family, for example, but now needs more help than the family is able to provide with daily activities such as bathing, eating or preparing food, or making sure they take their prescription drugs.
Sometimes, a patient might need to move to assisted living after a hospital stay, when they find they are no longer able to live alone safely. In that case, a designated hospital employee might fill out the PASRR so that when the person is ready to be discharged they are clear to move into assisted living.
Challenges mark new approach
Overall, we think that its working, from the point of view that only the people who need that level of care should be admitted to those facilities, said Vicki Smith, executive director for Disablity Rights North Carolina. And its about time that was the case.
But almost as soon as the PASRR requirement went into effect, it became apparent that getting the form filled out could be a major challenge.
A doctor who knows a patient well, has the patients medical file in hand and is comfortable working on a computer could fill out the online form in 15 minutes, state officials and county social workers say. But some doctors dont use computers, or are not willing to take the time required to complete the form because they dont get paid to do so.
Some patients who suddenly are not able to live alone anymore dont have a regular doctor who knows their history. In that case, a social worker may have to try to piece the history together, which can take days or weeks.
If the patient has been admitted to a hospital, and needs to be discharged to a family care home because they are no longer able to live alone, a hospital social worker might be able to gather enough information to fill out the form. But not all hospitals have staff dedicated to this task.
In any case, if the patient screens positive for severe and persistent mental illness and requires a face-to-face interview with the state, setting up and completing the interview can add several more days to the process.
We have had to pay somebody to go see a person and fill out a PASRR, said Craig Burrus, program manager of Senior and Adult Services for Wake County Human Services, whose departments work includes adult guardianship.
The county is the court-appointed guardian for about 700 adults, Burrus said, and some of those have had problems getting the forms filled out so they could move into adult-care homes.
In one case this year, he said, a client under the countys guardianship was involuntarily committed in a hospital elsewhere in the state.
They were there three or four weeks beyond when they were ready for discharge, Burrus said, waiting for this process to play out.
As long as the hospital agrees to keep the person until they have a safe place to move to, the patient is not in any danger, Burrus said. But hospitals absorb the cost of keeping such patients, and Burrus has worried that a hospital would discharge a patient to avoid that cost.
Or, he said, the patient might be living alone or with family who arent able to look after them properly. In either case, patients might stop taking medications or develop other problems that would put them at risk.
Don Dalton, spokesman for the N.C. Hospital Association, said hospitals across the state have reported having to keep patients up to five days beyond the date they were ready for discharge as a result of the new process.
I know it has been a concern, among hospital administrators, Dalton said.
In some cases, Burrus said, hospitals have refused to take patients with mental illness because they did not want to be responsible for keeping the patient once theyre medically stabilized but waiting for a form to be completed.
Jessica Bradley Keith, special adviser on ADA compliance for the Department of Health and Human Services, the agency responsible for putting into effect the agreement with the U.S. Department of Justice, said in October that about 1,300 forms had been submitted each month since the screening began in January, and that about the same number of individuals total 1,300 had been found to have a serious mental illness during that time.
The state has not said how many of the people found to have mental illness ultimately moved into adult care homes and how many went into other living arrangements, or what type arrangements.
Further changes to come
But Keith said the state is aware of delays in placements caused by the new process and that it is working to speed things up
One improvement, she said, will be to no longer require PASRR forms for individuals who would pay privately to live in adult care homes. Private-pay clients make up about 40 percent of those moving into such facilities, she said. Patients whose care is paid for by Medicaid would continue to need the form.
Also, because the face-to-face interview is redundant and adds about five days to the placement process, Keith said, the state would do away with that requirement. If the patients history indicates a severe and persistent mental illness, he or she will be scheduled to meet with a mental health worker who can talk with them about options besides adult care homes.
Those changes should be in place by the beginning of next year, Keith said.