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Preadmission Screening and Resident Review (PASRR) regulation and its implications for patients, hospitals, nursing homes, and the taxpayers

Subramonian Madhusoodanan, MD

Department of Psychiatry, St. John’s Episcopal Hospital, Far Rockaway, New York, USA, SUNY, Brooklyn, New York, USA

Sylvester A. Nwedo, MD

Department of Psychiatry, St. John’s Episcopal Hospital, Far Rockaway, New York, USA

Ronald Brenner, MD

Department of Psychiatry, Mercy Medical Center, Rockville Center, New York, USA, SUNY, Brooklyn, New York, USA

Omar Mirza, DO

Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, New York, USA

Background: This study assessed the impact of the revision of the Preadmission Screening and Resident Review (PASRR) regulation changes in September 2011, which increased the turnaround time for PASRR evaluations from 3 to 5 days to 2 to 3 weeks.

Methods: From January 2013 to March 2013, we tracked all patients’ charts in a 25-bed inpatient geriatric psychiatric unit in New York where PASRR evaluations were requested. The turnaround time and related issues were analyzed.

Results: There were 27 patients who had PASRR requests during the study period; 9 patients were not included in the study because of incomplete data. The average turnaround time for the 18 patients was 14.89 days and the additional hospital bed cost per patient was $11,911.11.

Conclusions: Although PASRR has played a positive role in identifying persons with serious mental illness and the need to provide the services they need, the recent revision of the PASRR regulation in 2011 has significantly increased the hospital bed costs.

Keywords: PASRR, implications, hospital, nursing homes



The mental health policies of a society reflect how the lawmakers and the general public view the mentally ill. From early 18th century to the present, public mental health policy in the United States has undergone many reforms and changes in an attempt to address the needs of seriously mentally ill individuals. The first major reform of the American mental health policy was moral management and introduction of asylums in the early 18th century. Edward Shorter, in his textbook of the history of psychiatry, described these asylums as vast warehouses for the chronically mentally ill.1 At its peak, the population in American psychiatric institutions swelled to nearly 560,000 in 1955 with Pilgrim State Hospital in Brentwood, New York housing nearly 10,000 patients.2

A second major policy change began in the middle of the 20th century; deinstitutionalization and origin of community mental health centers was concurrent with the antipsychiatry movement of the 1960s to 1970s. Catalyzed by the introduction of chlorpromazine, the first FDA-approved treatment for psychosis, and a growing public resentment of the mistreatment of individuals in asylums, a shift towards reintroducing patients into the community began to take hold. This was bolstered by the Community Mental Health Act of 1963, which provided federal funding for community mental health centers, and significantly eased the financial burden on the state for caring for mentally ill individuals. Asylums across the country saw a nearly 80% decline in the number of institutionalized patients from 1955 to 1988.3

Although well intended, the community mental health centers were ill prepared for the influx of actively sick patients who were being released to the community. Many patients became victims of violence, contributing up to one-third of the nation’s homeless population, and up to 14% of individuals in the criminal justice system.4 The Rockaway peninsula had approximately 4,000 chronically mentally ill patients in various nursing homes, adult homes, and group homes in 2011, most of them were discharged from state psychiatric hospitals.

The Omnibus Budget Reconciliation Act mandated that all individuals with serious mental illness (SMI) or mental retardation (MR) applying for nursing home placement be identified, placed appropriately, and receive services that they need in an appropriate setting. Also, residents of nursing homes with SMI or MR need to be reevaluated if they experience a significant change in their physical or mental status.

The Americans with Disabilities Act passed in 1990 and the Supreme Court’s Olmstead decision of 1999, banned states from unnecessarily institutionalizing persons with disabilities and not providing service in the most integrated setting appropriate to patients’ needs. Therefore, patients with SMI or MR who are applying for admission to residential healthcare facilities must complete a community or hospital patient review instrument and a screen form. This involves a federally required Level I review process to determine if the individual has possible SMI or MR. In New York State, patients identified during this screening as having possible SMI, and do not meet the criteria for a categorical determination, are referred to IPRO (formerly known as the Island peer review organization) for a Level II determination.5

With the revision of the Preadmission Screening and Resident Review (PASRR) regulation and New York State Department of Health regulations, which became effective in September 2011 in response to a court order, the turnaround time for obtaining the PASRR approvals increased from 3 to 5 days to 2 to 3 weeks. Survey data suggest that many nursing home staff and long-term care professionals are not satisfied with the preadmission screening and feel that the procedure should be eliminated.6,7

Preadmission screening of nursing home residents with mental illness is the most criticized component of the reform,8 but it has the fewest data-based studies and more data are needed to evaluate the financial cost of the reform and how it affects the quality of life of the SMI nursing home residents.


We conducted a retrospective study regarding the turnaround time between PASRR request and response in a geriatric inpatient psychiatric unit in New York over 3 calendar months from January 2013 to March 2013. This study was approved by the institutional review board of St. John’s Episcopal hospital. Data points gathered included the date Level II determination request was faxed to IPRO, the date IPRO picked up the documentation and reviewed the chart, and the date IPRO responded. These data points were examined to extrapolate the turnaround time in days from the date Level II determination request was faxed to IPRO and the date IPRO reviewed the chart, the time to receive a response following the chart review, and overall turnaround time calculated from the initial request to response from IPRO. The total turnaround time was multiplied by the average per diem cost of hospitalization of Medicare and Medicaid reimbursements, which is $800 per day, to calculate the additional financial cost because of extended hospitalization while awaiting Level II determination. A descriptive analysis was used to measure the turnaround time from the day of PASRR request to the day of IPRO response. This was the primary measure of outcome of interest for the financial analysis.


Twenty-seven requests were made for Level II determination during the calendar months of January 2013 to March 2013. Nine patients had incomplete data and were removed from the analysis leaving 18 complete sets of data. The mean calendar days from the day Level II requests were faxed to chart review and pickup of documentation by IPRO was 3.89 days with the shortest time being 2 days and longest 7 days. The mean number of days between pickup of documentation and response from IPRO was 11 days, with the shortest being 7 days and the longest 21 days (TABLE). The mean total turnaround time between faxing of Level II request and receipt of IPRO response was 14.89 days, with 10 days being the shortest and 24 days being the longest (FIGURE 1). The additional cost incurred while the patient was awaiting Level II determination was $11,911.11 per patient. The cost for the 18 patients amounts to $214,400 because of the delayed discharge secondary to Level II determination in a 25-bed inpatient unit (FIGURE 2). The annual additional cost of the turnaround time translates to $857,600.


Turnaround time for Level II determination

Patient Date Level II faxed to IPRO Date IPRO reviewed chart + pick-up Was the patient assessed? Date IPRO responded Days until pickup Days from pickup until response Total days from fax to response
1 12/26/12 12/31/12 Yes 1/7/13 5 7 12
2 12/27/12 12/31/12 Yes 1/7/13 4 7 11
3 12/27/12 12/31/12 Yes 1/7/13 4 7 11
4 1/31/13 2/1/13 Yes 2/20/13 1 19 20
5 2/19/13 2/21/13 Yes 3/8/13 2 15 17
6 2/14/13 2/21/13 Yes 3/5/13 7 12 19
7 2/5/13 2/8/13 Yes 3/1/13 3 21 24
8 2/19/13 2/21/13 Yes 3/5/13 2 12 14
9 2/14/13 2/21/13 Yes 3/6/13 7 13 20
10 2/15/13 2/21/13 Yes 3/6/13 6 13 19
11 2/19/13 2/21/13 Yes 3/4/13 2 11 13
12 2/5/13 2/8/13 Yes 2/22/13 3 14 17
13 2/15/13 2/21/13 Yes 3/1/13 6 8 14
14 2/25/13 2/27/13 Yes 3/8/13 2 9 11
15 3/6/13 3/11/13 Yes 3/18/13 5 7 12
16 3/8/13 3/11/13 Yes 3/18/13 3 7 10
17 3/15/13 3/19/13 Yes 3/27/13 4 8 12
18 3/15/13 3/19/13 Yes 3/27/13 4 8 12

FIGURE 1: Turnaround time from fax to response

FIGURE 2: Financial cost of Level II turnaround time


Mental health policy development in the United States has been cyclical in nature, which has had a significant impact on individuals with SMI. This study started with a review of the literature about US mental health policies and how they affected the quality of care of seriously mentally ill individuals in relation to observations on preadmission screening and resident review in a geriatric inpatient psychiatric unit in New York.

The prolonged hospital stay causes a significant taxpayer expense to cover the additional days of hospitalization, risk of hospital acquired infections and exposure to medical errors, patient right issues, shortage of acute psychiatric beds, and almost an automatic loss of the 14-day bed hold for nursing homes.

In a scathing article in the March 2012 issue of the American Association of Retired Persons bulletin, Katherine Greider states that US hospitals may be to be the worst place to stay when you are sick. In the United States, approximately 100,000 deaths annually are secondary to hospital errors.9 In a study of Medicare patients, the US Department of Health and Human Services found that 1 in 7 suffered serious or long-term injuries or died as a result of hospital care.10 Hospital-acquired infections also contribute to morbidity and mortality statistics. Keeping patients—especially vulnerable, disenfranchised individuals with SMI—in hospitals for longer than needed exposes them to these adverse events.

Total annual expenditures will be much more than our estimate because the 9 cases with incomplete data sets have not been accounted for in our calculations. If these cases were included the annual expenditure may hit close to $1,000,000. As seen in FIGURE 2, the total hospital bed cost to achieve clinical stability is much less than that for Level II turnaround time. However the number of IPRO requests for Level II may be higher in our institution because of the large number of nursing homes, adult homes, and group homes in our area, with >4,000 patients with SMI.

There are several unexplored scenarios that might occur in connection with these issues. A SMI nursing home patient who is on a voluntary status and deemed ready for discharge requests immediate discharge while awaiting Level II determination. Under current regulations, the hospital cannot discharge the patient and the nursing home cannot accept the patient without the Level II determination. If this patient requests a court hearing, what will be the court decision? We believe this may violate the patient’s rights and impair his quality of life. A second possible situation is regarding the commercially insured patients. Will commercial insurances pay for the hospital days spent waiting for Level II determination? The issue of whether these patients should be on alternate level of care also needs to be considered. Because the IPRO’s decision may vary as to whether the patient can be discharged or need “specialized services,” there is no clear answer to this question.

We recommend the following to address the issues with turnaround time. Level II determination may be done as a 2-part process. Historical data collection might be done during admission via electronic transfer or fax transmission. When patient is clinically ready for discharge, an updated evaluation about the hospital course and current mental status might be transmitted to IPRO and then a decision should be made within 2 to 3 days on the appropriateness of discharge to the nursing home or the decision can be left to the treatment team. If there is a dispute between the treatment team and the nursing home, IPRO could be involved to rectify the situation. The above measures will reduce the hospital stay expenses and the expenses related to the IPRO evaluation.

There has been little research on PASSR even though it has been highly criticized. Our study has limitations. The sample size is small; however, it is a pilot study. The impact of the regulation on quality of care issues for patients was not measured because we focused on the additional financial costs. The financial cost calculation may vary depending on the reimbursement rate for an individual hospital and the level of the patient’s care (acute or alternate). The morbidity and mortality effects of prolonged hospitalization also needs to be measured systematically. Future studies should address the financial burden and the morbidity and mortality implications of prolonged hospital stay, secondary to PASRR turnaround time.


Although PASRR has played a positive role in identifying persons with serious mental illness and the necessity to provide the services that they need, the recent revision of the 2011 PASRR regulation has significantly increased the cost of hospital stay. Because of the high number of patients with SMI in nursing homes, there is an urgent need to improve these policies to minimize the impact of prolonged hospital stays in a locked setting.

Disclosures: Dr. Brenner receives grant/research support from EnVivo, Forest Pharmaceuticals, Johnson & Johnson, Lundbeck, Otsuka, Roche, Sunovion, and Takeda; is a consultant to Lundbeck and Otsuka; and is speaker for Lundbeck, Novartis, and Otsuka. Drs. Madhusoodanan, Nwedo, and Mirza report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.


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CORRESPONDENCE: Subramonian Madhusoodanan, MD, St. John’s Episcopal Hospital, 327 Beach 19th Street, Far Rockaway, NY 11691 USA E-MAIL: sdanan@ehs.org