What Is a Nursing Home Pre-Admission Assessment?

Why Evaluating Potential Residents Is So Important in Skilled Nursing Facilities

Nurse conducting pre-admission assessment
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Most skilled nursing facilities conduct evaluations of potential residents before admitting them for care, whether that's for short-term sub acute rehab, long-term care, or dementia care. These pre-admission assessments can help determine the needs of the person and ensure that the facility is properly equipped to handle those needs. Identifying which components to assess, as well as understanding why pre-admission evaluations are so important, can facilitate an improvement in the Centers for Medicare & Medicaid Services (CMS) five-star quality measures and resident satisfaction.

Assessment Components

Demographics

This information includes name, date of birth, sex, and address. 

Basic Medical History

This includes information such as height and weight, allergies to medications or foods, and a complete list of diagnoses. You should also review a recent history and physical to get a good picture of the medical picture of this potential resident. (A history and physical is required for admission, so reviewing it ahead of time is essential.)

If appropriate, ask if there has been any hospice or palliative care involved in her care, as this will affect her plan of care as well as the potential for Medicare coverage.

Insurance, Finances, and Payment 

Verify Insurances

Collect insurance information to determine if coverage is available. Insurance, including Medicare, Medicaid, long-term care insurance, and other private insurances all need to be verified for coverage and for authorization procedures.

Medicare or Medicare Advantage Plan Prior-Authorization

Most Advantage Plans require that the facility acquire prior authorization in order to get paid for sub-acute rehab. This means that the insurance plan verifies and agrees to cover the person for a certain amount of days. Further coverage beyond these initial days is often granted but is based on updated information after the individual has been living at your facility for a few days.

Requirements and timing are often different for the various insurances, so you will want to ensure that you are aware of those specifics. 

Traditional Medicare coverage doesn't require any prior authorizations, but you will want to ensure that the potential resident is appropriate medically for Medicare Part A coverage, so that when you conduct your Minimum Data Set (MDS) assessment, you're not surprised at her level of care.

Private Pay or Medicaid Eligibility

If a potential resident is planning to live at your facility and receive long-term care services, determine if there are private funds available or if she would qualify for Medicaid coverage for nursing homes. It's important to ask enough questions to know whether she has already been approved for Medicaid, if she's applied for Medicaid and his application is pending, whether she will be likely to be approved, and if she's given money away (divested funds) that would disqualify or delay him from getting Medicaid approval.

Medicaid Level of Care Assessment

If your potential admission is moving to your facility from his home and plans to be covered by Medicaid, be sure to unofficially assess his level of care per your State's Medicaid level-of-care tool.

While you can't enter this evaluation into the Medicaid system before the individual is admitted to your facility, you need to know that Medicaid will cover his care if she becomes a resident at your facility. Medicaid requires both financial and medical eligibility.

Essentially, you are assessing if the prospective resident has enough care needs in order for Medicaid to cover his care at your facility. Or, does she need to somehow find some more services at his own home because she is "too good" to be covered by Medicaid at a long-term care facility?

Family and Support System

Your assessment should identify the names and contact information for family and resident representatives, including if a power of attorney for healthcare or finances exists, as well as if a legal guardian has been appointed through the court.

 It's also important to determine if there are others who can support the resident if family members aren't available.

Language and Communication Ability

Identify the potential resident's primary language to determine if an interpreter will be needed. You are required to ensure adequate communication with the resident.

In addition to language, it's also important to evaluate the resident's ability to communicate needs and understand communication from others. A diagnosis such as Alzheimer's disease can limit both expressive and receptive communication.

A potential resident's ability to communicate can also be affected by her hearing and vision ability. 

Medication List and Pharmacy Cost Estimate

Be sure to review a complete list of medications that are prescribed for the referred individual. You need this for two reasons.

The first is so that you can care correctly for the person. A full medication list is required in order to admit someone into your facility per the regulations. You need to know the entire medication regimen, so ask if there are any natural substances or supplements that she is taking.

The second reason to review medications is related to finances. If Medicare A or a Medicare Advantage program is the primary payer source, the facility is required to pay for all of the medications for that person. This is because the cost of medications is included in the daily rate paid under sub-acute rehab insurance reimbursement, but that rate is not adjusted based on which medications are prescribed.

Some situations are very unfortunate because the referred individual needs inpatient rehab and you could meet her needs, but she might be on a medication that costs far more than the daily rate your facility will get paid to care for her. 

Durable Medical Equipment

What equipment needs are there? For example, is she on oxygen? Does she use a walker or a wheelchair to get around? Does she sleep with a CPAP machine due to sleep apnea? While some of these pieces of equipment might come with a new admission, others (such as oxygen) will need to be started upon arrival to your facility.

Additionally, some durable medical equipment can be expensive, so the cost of the equipment may affect the decision of if your facility can financially care for the resident.

MDS Info

When a resident of a long-term care facility moves from one facility to another one, you can ask for the Minimum Data Set (MDS) information. This should give you a good picture of her needs, so that you can ensure your ability to meet them.

Physical Assistance Needs

If you don't have access to an MDS or a physical or occupational therapy evaluation, you need to review the levels of assistance needed.

For example, does she need help of one person or two to transfer? Can she move in bed independently or need assistance? Does she eat independently or does she require assistance? What about her ability to walk? Does she need help with dressing? Is she continent of bowel and bladder, does she use some products to help manage that, or does she need to be prompted to void at certain times of the day? All of this information can help you understand the whole picture of how to care for this potential resident at your facility.

History of Falls

Determine if she has had any recent falls. If so, ask when and what happened, so that you can use this knowledge to be proactive with his medical care and attempts to reduce his falls.

Skin Condition

It's important to know if someone is coming to you with any open areas, such as a pressure sore. You need to know this to evaluate your capability to provide the necessary care as well as to document that she is coming to you with that sore, rather than finding that sore after his admission and being unable to prove she had it prior to coming to you. You also need to be aware of the cost of the treatment that is prescribed for any pressure sore.

It's also important to ask about any bruising, including current bruises as well as a history of bruising easily due to anticoagulants such as Aspirin or other risk factors.

Cognitive Functioning

If you're assessing someone who lives in the community, it's important to get a picture of his cognitive functioning. At minimum, you can ask questions about his memory and decision-making ability. If you're traveling out to assess him in person, you can use the BIMS, SLUMS or MoCA to evaluate it in more detail, if you feel that it is appropriate.

Level of Dementia Care Required

If the potential resident has dementia, consider if she needs a secure dementia unit or if she will be safe in a more open unit. Identifying the elopement risk is important because once you admit the resident into your facility, you are responsible for her safety, including preventing her from wandering out the door.

Emotional and Psychiatric Needs

Identify any mental illness or psychiatric diagnoses the potential resident has and ensure that you have the ability to meet those needs. This includes diagnoses such as schizophrenia and post-traumatic stress disorder. 

Behavior Concerns

Identify any behavior concerns present. These are especially likely in those who are living with dementia. Rather than ask a general question about "difficult behaviors," ask if she gets frustrated or angry when she's receiving care, if she attempts to leave the house, or for which specific reason she receives a psychoactive medication. If you're considering a referral from the hospital, be sure to ask if she's had a "sitter," "one-on-one" staff member, or increased monitoring due to behaviors.  

Substance Abuse

You will need to know if there is any history of substance use or abuse, whether it be legal or illegal drugs. An identified concern in this area will impact your treatment plan for this resident.

Prior Living Arrangements

For short-term rehab patients, clarify where they have been living up to this point, and if their living arrangements will allow them to return there after they receive rehabilitation at your facility.

Discharge Plans

Similarly, discharge planning should begin before a resident ever sets foot in your door. It's important to identify their plans and wishes so that you are intentional about evaluating the safety of those plans and moving toward them.

Questions and Tour

Allow time for the resident and responsible party to ask questions about your facility and encourage them to come tour it to make sure it is a good fit for them. You may be eager to fill your beds, but allotting time for these steps upfront can save you time later.

Previous Negative Experiences

If the interested person is hoping to transfer from another similar facility, politely ask her if she would care to share her reasons why she'd like to move.

While there are times where simple logistics (like facility location) may be prompting the change, there may be other cases where there's been a significant problem with the care the person received in another facility. Identifying these concerns before admission can allow you to discuss how your facility would handle them and provide the potential resident with insight as to whether she still wants to make a move to your facility. It also allows you to gain knowledge about the expectations she has and determine if you can meet them.

Importance of Pre-admission Assessments

A pre-admission assessment takes time to conduct, but it is generally time well-spent. Here are a few reasons why they're so important.

First, once you admit a resident, you are fully responsible for her care. Knowing what those care needs are is a must.

Furthermore, CMS regulations make it difficult to involuntarily discharge someone—a protection for the overall care and well-being of the resident. Thus, if things don't go well or there are a high level of needs that you weren't aware of, you can't just send that person somewhere else.

Pre-admission assessments also are helpful for risk management. Knowing resident concerns ahead of time makes it more likely that your staff can work to address them.

As mentioned earlier, the financial impact of an admission is also important. While the focus of many people who work in a nursing and rehab facility is to care for their residents, your organization has to remain financially viable in order to continue to provide those services to those who need them.

A pre-admission assessment is also important as it relates to the CMS phase two requirements of participation—specifically, that of the facility assessment and the competencies of staff. The facility assessment identifies which medical needs the facility is competent to meet, while the competencies requirement addresses the need to ensure that your staff (on an individual basis) can satisfactorily and competently meet each of those needs.

A Word From Verywell

Conducting a thorough pre-admission assessment has many benefits, both for the facility and for the resident's quality of care. Ultimately, it can help you meet the goal of ensuring that the admission process flows more efficiently and effectively for all those involved.

Sources:
Delaware Health and Social Services. Division of Medicaid & Medical Assistance. Pre-Admission Evaluation (PAE) Long Term Care Tool-001. http://clpc.ucsf.edu/sites/clpc.ucsf.edu/files/Delaware%20Pre-Admission%20Evaluation.pdf

Scott & White. UDS-Pro. Pre-admission Assessment. http://www.sw.org/resources/docs/patient-forms/uds-pro-pre-admission-assessment.pdf

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