By Elizabeth W. Teet, DM, MPA, ABDA, CPM, QIDP 

In 1987, President Ronald Reagan signed into law the first significant revision of the federal standards for nursing home care since the 1965 creation of both Medicare and Medicaid (42 U.S.C. 1396r, 42 U.S.C. 1395i-3, 42 CFR 483). The landmark legislation forever changed society’s legal expectations of nursing homes and their care. Long-term care facilities wanting Medicare or Medicaid funding are to provide services so that each resident can attain and maintain the highest practicable physical, mental, and psycho-social well-being.  

The Federal Nursing Home Reform Act or OBRA ‘87 creates a national minimum standard of care and rights for people living in certified nursing facilities. This landmark federal legislation comes by its common name, “OBRA,” through the legislative process. Congress usually completes most budgetary and substantive work in one large bill. The bill accomplishing that function in 1987 was entitled the Omnibus Budget Reconciliation Act of 1987 or “OBRA ‘87.” The Federal Nursing Home Reform Act and many other bills were “rolled into” one bill to ensure all elements' final passage.  These minimum federal health and care requirements for nursing homes must be delivered through various established protocols within nursing homes and regulatory agencies. As minimum standards, professionals should view OBRA as a baseline that should be built upon to reach not only resident “well-being” but also happiness, fulfillment, and quality of life.  The changes OBRA brought to nursing home care are enormous. Just like individuals  admitted to hospitals have a “Patient’s Bill of Rights” because of OBRA, long-term care residents also now  have a “Resident’s  Bill of Rights.” Some of the most essential resident provisions include:   

  • Emphasis on a resident’s quality of life as well as the quality of care.  
  • New expectations that each resident’s ability to walk, bathe, and perform other activities of daily living will be maintained or improved without medical reasons.  
  • A resident assessment process leading to the development of an individualized care plan.  
  • Rights to remain in the nursing home absent non-payment, dangerous resident behaviors, or significant changes in a resident’s medical condition.  
  • New opportunities for potential and current residents with intellectual disabilities or mental illnesses for services inside and outside a nursing home.   
  • A right to safely maintain or bank personal funds with the nursing home. 
  •  Rights to return to the nursing home after a hospital stay or an overnight visit with family and friends.  
  •  The right to choose a personal physician and to access medical records.   
  • The right to organize and participate in a resident or family council.   
  • The right to be free from unnecessary physical and chemical restraints.   
  • Uniform certification standards for Medicare and Medicaid homes.  
  • Prohibitions on turning to family members to pay for Medicare and Medicaid services;  and  
  • New remedies to be applied to certified nursing homes that fail to meet minimum federal standards.  

OBRA set in motion forces that changed how state inspectors approached all their visits to nursing homes. Inspectors no longer spend their time exclusively with staff or with facility records. Conversations with residents and families are a prime-time survey event. Observing dining and medication administration is a focal point of every annual inspection.  Under OBRA, long-term care ombudsman programs have defined roles to fulfill and tools to use in the annual inspection process to nurture conversations between residents/families and inspectors about life in the nursing home.   

How Did OBRA ’87 Come About? 

 The federal Nursing Home Reform Act became law with growing public concern about the poor quality of care in too many nursing homes and the concerted advocacy of advocates, consumers, provider associations, and health care professionals. Congress asked the Institute of Medicine (IOM) to study how to regulate better the quality of care in the nation’s Medicaid and Medicare-certified nursing homes.  In its 1986 report, “Improving the Quality of Care in Nursing Homes,” the expert panel recommended:    

  • A more substantial federal role in improving quality.  
  • Revisions in performance standards, the inspection process, and the remedies to improve nursing home services.   
  • Better training of nursing home staff.  
  • Improved assessment of resident needs; and 
  • A dynamic and evolutionary regulatory process.   

Their consensus positions on the IoM report laid the foundation for the federal law.  OBRA has changed the care and lives of nursing home residents across America. Significant improvements have been made in the comprehensiveness of care planning. Anti-psychotic drug use declined by 28-36%, and physical restraint use was reduced by approximately 40%.  

 Several states have adopted all or parts of OBRA ‘87 and made it law for licensed nursing homes or other long-term care facilities. For example, the state of Washington has extended nursing home residents' rights to residents of all Washington long-term care facilities. Michigan has incorporated many OBRA prohibitions on Medicaid discrimination into state law.   

Preadmission Screening and Resident Review (PASRR) 

The federal Omnibus Reconciliation Act mandates Preadmission Screening and Resident Review (PASRR) and helps ensure that individuals are not inappropriately placed in nursing homes for long-term care. PASRR requires that Medicaid-certified nursing facilities, regardless of payment source: 

  • Evaluate all applicants for evidence or history of serious mental illness (SMI) and/or intellectual /developmental disability (IDD) 
  • Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings) 
  • Provide all applicants with the services they need in those settings 

PASRR is an essential tool for states to use in rebalancing services away from institutions and towards supporting people in their homes and to comply with the Supreme Court decision, Olmstead vs. L.C. (1999), under the Americans with Disabilities Act, individuals with disabilities cannot be required to be institutionalized to receive public benefits that could be furnished in community-based settings. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care. 

In brief, the PASRR process requires all applicants to Medicaid-certified nursing facilities to be given a preliminary assessment to determine whether they might have SMI or IDD. This is called a "Level I screen." Those individuals who test positive at Level I are then evaluated in depth, called "Level 2" PASRR. The results of this evaluation result in a determination of need, a determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. 

Regulations governing PASRR are found in the Code of Federal Regulations, primarily at 42 CFR 483.100-138 

Impact on Case Management 

When an individual is hospitalized and unable to return to previous living arrangements, needs extended care beyond acute care or acute rehabilitation, or whose health has continued to deteriorate and requires medical management beyond the ability of community services, there may be recommendations for transitioning to an alternative level of nursing care or medical management. If the care discussion along the continuum includes long-term care, PASRR regulations may need to be part of the discussion and planning. Without compliance with these regulations, the individual may not be able to be admitted to or receive and have care paid for by Medicaid in a long-term care facility.  

Case Managers may be requested to participate in the PASRR process in several ways. 

  • Level I screening is a preliminary assessment conducted in a hospital, emergency room, doctor's office, or other community setting. Case managers may be involved in completing this initial screening process, which identifies individuals who may have a PASRR condition. 
  • Case managers may be involved in the more in-depth evaluation process for individuals with a PASRR condition. An example is to collaborate with PASRR evaluators for access to data and records review for completion of the written evaluative reports (Level 2 PASRR) or consultations in recommending the most appropriate setting for an individual, such as a nursing facility, alternative care setting, or the community.  
  • Since federal law prohibits payment for nursing facility services until the PASRR screening has been completed, understanding of PASRR regulations and the role of the case manager in the process removes any potential barrier to timely hospital discharge, admission to long-term care, or movement along the continuum of care.  

For additional support or guidance, contact the individual state Medicaid Authority, Department of Developmental Disabilities, Department of Mental Health Services, National Association of PASRR Professionals (pasrr.org), or PASRR Technical Assistance Center (pasrrassist.org).  

References 

Center for Medicare and Medicaid Services, CMS, n.d. Federal Regulations: 42 CFR 483.25 http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr483_02.html  

Institute of Medicine (US) Committee on Nursing Home Regulation. Improving the  

Quality of Care in Nursing Homes. Washington (DC): National Academies Press  

(US); 1986. PMID: 25032432. 

https://www.ecfr.gov

Medicaid Provision: 42 U.S.C. 1396r(b)(4)  

http://www4.law.cornell.edu/uscode/42/1396r.html   

Medicare Provision: 42 U.S.C. 1395i-3(b)(4)  

http://www4.law.cornell.edu/uscode/42/1395i-3.html   

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Bio: Elizabeth W. Teet, DM, MPA, ABDA, CPM, QIDP, is passionate about a person-centered approach, education, care coordination, advocacy, and quality care. She has been in the healthcare industry for 40+ years as a medical social worker, case manager, Director of Case Management, Area Director of Managed Care, administrator, mentor, and leader in different practice settings. Elizabeth is an author and speaker at both the local and national levels on person-centered approach, case management, patient advocacy, care coordination, integrated healthcare, and regulations.  Her professional social work case management background has enhanced her ability to advocate for her current work with Oklahoma Human Services, PASRR Program for Developmental Disabilities. She participates on the OAHCP faculty for the state-approved certification program for long-term care Social Services Directors. She also participates as ancillary faculty for the Oklahoma State Board of Examiners for Long Term Care Administrators University. Elizabeth has long devoted her free time to NPO leadership. Elizabeth served The Case Management Society of America in leadership positions for the national and local chapter board of directors. She is Chair of the Board of Directors for the National Association of PASRR Professionals.